---

Introduction

Teenagers with Down syndrome have specific speech and language impairment - that is, their speech and language skills are significantly more delayed than their non-verbal abilities. This situation can be frustrating for young people with Down syndrome and can lead to their cognitive and social understanding being underestimated. Among teenagers there is considerable individual variation in rates of progress, with some teenagers able to use more spoken language than others.

Language

Most teenagers will have a range of vocabulary relevant to their everyday needs and interests and will be speaking in short sentences. They will all be continuing to learn new vocabulary for school topics and for age-appropriate hobbies and leisure interests. Their sentences may not contain all the grammatical words but may be rather 'telegraphic' e.g. ''he sit chair'' rather than ''he is sitting on the chair'' or ''me go France Tuesday'' rather than ''I am going to France on Tuesday''. Almost all teenagers will understand more language than they can use in their own speech.

Speech intelligibility

Many teenagers have difficulty speaking clearly, that is, the words and sentences that they say are not always easy for the listener to understand due to speech production delays and difficulties. Between 25% and 50% of teenagers are reported to have speech that is unintelligible to people who are meeting them for the first time.

Social communication

Many teenagers are socially confident and wish to communicate, but they may still need help to develop social language and the confidence to initiate conversations and manage social situations appropriately.

Therefore three aspects of speech and language - developing vocabulary and expressive grammar, improving speech clarity and developing confident social conversational skills - should be addressed for all teenagers with Down syndrome. The guidance provided in this module is written to be relevant for teenagers in special or mainstream education settings.

However, because of the very wide range of progress in any group of teenagers with Down syndrome, it is difficult to write guidance that is relevant for every individual.

The teenagers with the least speech and language delay may start secondary school at 11 years of age with the ability to use mainly complete grammatical sentences in their spoken language and with reasonably clear and intelligible speech. The teenagers of this age with the greatest speech and language delay may only have a small vocabulary and use mainly one and two word phrases in their daily communication. In a recent study conducted by the authors,^[1,2] 7 out of 46 teenagers (15%) had less than 100 words in their spoken or signed vocabularies and used mainly single words to communicate.

In order to ensure that the needs of the teenagers with the most delayed speech and language skills, as well as the needs of the most language advanced, are addressed in this module, speech and language development from the early stages to full adult competence is covered. A set of checklists covering vocabulary, grammar, speech and communication development from the early stages, is available for use with this module and the authors encourage everyone to make use of them, as even the most advanced teenagers may not have mastered all the grammar words, sentence structures, speech sounds and conversational skills covered by these checklists.

Vocabulary

Checklists for a core 800-word vocabulary, including the most important grammatical words, are available from DownsEd (see box). Many teenagers, especially those who have been in mainstream schools for their primary education, will have all or most of these words in their vocabularies already, but there will be many (probably about 50% of 11 year olds) who do not have all these words in use in their spoken vocabularies, particularly the grammatical words.

Sentences and grammar

A checklist for sentences and grammar is available, as many teenagers will still be using 'telegraphic' sentences in their speech, rather than grammatically complete ones.

Speech sounds

A checklist for speech sound production covers the use of the speech sounds and sound combinations used in English, in different positions in words, to help identify the speech sounds with which teenagers may still be having difficulties.

Interactive communication skills

The checklist covering play and interactive skills includes early play and communication skills that almost all teenagers will have achieved but it also includes some examples of conversational skills that many will not yet have achieved.

A future project for the authors will be to develop a second set of checklists, which will be specifically adapted to be relevant to teenagers and adults. Meanwhile the current ones should be helpful, particularly for parents and teachers who have not had experience of working with young people with significant speech and language delays.

In summary, the main aim of this module is to provide practical advice and activities to improve the spoken language skills of teenagers with Down syndrome during their secondary school years. The focus is therefore on developing and extending their use of vocabulary, grammar and sentences and on improving their sound production skills to increase the intelligibility of their speech, at home, at school and in the community.

1. What do we know about the speech and language development of teenagers with Down syndrome?

The skills and knowledge needed for talking

For all children, learning to talk is a complex process, involving a number of emerging skills, influenced by learning opportunities and developed over many years. To be competent at expressing themselves through language, children have to know the words and grammar needed to express their thoughts in spoken language, language knowledge, they have to be able to make the sounds and words clearly so that their speech can be understood, speech, and they have to know how to engage someone effectively in a conversation, interactive communication skills, (see Table 1). The reader is referred to Speech and language development for individuals with Down syndrome - An overview for a full discussion of these issues and the key findings from research for both typically developing children and children with Down syndrome.

For teenagers with Down syndrome speech and language skills are delayed relative to non-verbal reasoning ability

Teenagers with Down syndrome have a specific speech and language impairment - that is, their speech and language skills are delayed relative to their non-verbal abilities. This has been reported in several studies ^[6-8,15] and is illustrated in Table 2, which presents data collected from a group of 12 teenagers by the first author.^[3,4]

The Matrices (Raven's Coloured Matrices) is a test of non-verbal reasoning ability, requiring the teenager to choose the correct missing piece in order to complete a pattern. The patterns increase in complexity. The age-equivalent scores illustrate that vocabulary comprehension, measured by the BPVS (British Picture Vocabulary Scale), is 1 year 6 months behind non-verbal reasoning ability and that grammar comprehension, measured by the TROG (Test for Reception of Grammar), is 2 years behind non-verbal reasoning ability. The reader will also note that sentence length and complexity in the teenagers' spoken language, measured by MLU (Mean Length of Utterance - a count of morphemes), is more than 3 years delayed.

Usually, teenagers would be expected to show an even profile - that is, to have about the same age-equivalent skills across all their skills and abilities, verbal and non-verbal.

The fact that speech and language progress is delayed relative to non-verbal abilities, suggests that there are specific difficulties holding back progress. The speech and language delays of children with Down syndrome cannot simply be attributed to limited cognitive abilities, as their non-verbal cognitive abilities are ahead of speech and language abilities.

Specific auditory processing difficulties

The specific difficulties which might explain this profile include:

• hearing loss - some 80% of children with Down syndrome suffer from mild to moderate hearing loss in their early years, and this is likely to affect language learning
• impairment in phonological loop function - the part of the working memory system designed to hold the sound pattern of the word to enable spoken word discrimination and word learning
• impairment in verbal short-term memory spans in working memory. Verbal short-term memory spans are specifically delayed (but not visual short-term memory spans - these are usually appropriate for non-verbal abilities). This will affect the ability to listen to and to process sentences.

In other words, auditory discrimination and auditory memory processes are specifically impaired and these difficulties affect learning a spoken language from listening.

Young children with Down syndrome usually show by their behaviour that their understanding of the world and events around them is ahead of their ability to use words, and they often communicate effectively using natural gesture and taught signs before they can use words.

Visual learning strengths

Children and teenagers show visual learning strengths, that is they learn more effectively from what they see than from what they hear. The implication of all this information is that all learning should be supported with visual cues and visually presented information, e.g. using pictures, signs, symbols and print.

Print is particularly powerful, as written language is an accurate representation of the spoken form. A further implication is that activities to improve speech sound discrimination and verbal short-term memory may help to develop spoken language abilities.

The speech and language skills of teenagers with Down syndrome show strengths and weaknesses

In addition to an overall delay in speech and language skills relative to non-verbal abilities, there are also strengths and weaknesses within the component speech and language skills.

The uneven profile within the speech and language skills of teenagers with Down syndrome has been documented by a number of authors ^[5-11,14,15] and this pattern is also illustrated by the age-equivalent scores in Table 2.

Vocabulary learning is a relative strength, grammar comprehension is more difficult, but the most significant delay is in expressive grammar. The teenagers understand more grammar than they are able to use in their spoken language. Part of the explanation for their expressive language difficulties may be their speech-motor difficulties.^[12,13] It may be difficult for them to plan and then to organise and execute clear production of a string of six, seven or more words - with correct word endings and function or 'joining' words.

The teenagers may also have learned that when they try to say longer, complete sentences, they are less intelligible than when they use only three or four key words (nouns, verbs and adjectives). Using 'telegraphic' sentences may improve the success of their communication. ^[14,53]

The teenagers' working memory difficulties will also play a part in their grammar difficulties. Limited verbal short-term memory will affect the processing of longer sentences and will have reduced their ability to learn grammar. The phonological loop may also play a part in sentence production, so that limitations here will affect their ability to plan and produce sentences. ^[15,16]

However, most teenagers want to communicate and they make effective use of their language skills, so that their interactive communication skills are a relative strength.

Is there evidence of progress in speech and language during teenage years?

Among language researchers, there are differing views about the possibility of significant progress in speech and language skills during the teenage years. Some authors suggest that progress in expressive grammar and speech clarity is likely to be limited and difficult to achieve from 14 years onwards. On the other hand, they expect that progress in vocabulary and communication skills will be easier for teenagers and will continue into adult life. ^[11,17,18]

Some research studies have reported progress during teenage years. Robin Chapman has collected cross-sectional and longitudinal data with teenagers and young adults with Down syndrome in Wisconsin, USA. ^[5-8] She reports that, for a group of 12-20 year olds, there was evidence of progress over a four-year period on measures of vocabulary comprehension and non-verbal cognitive measures, but little progress in grammatical comprehension and production for the group as a whole. However, there was considerable individual variation and two of the nine older teenagers (16-20 at the start of the study) showed consistent MLU increase. Increases were more evident in narrative speech (telling a story) than in conversational speech (often involving questions and answers).

The authors' own studies^[1,2], reported in full later in this document, indicate progress with age through teenage years, for both receptive and expressive language and for pupils in both mainstream and special schools (although, as it is cross-sectional rather than longitudinal data, it is not conclusive evidence of progress with all). None of the published longitudinal studies report on any therapy available to the teenagers. It is possible that targeted therapy might further improve the progress of teenagers.

Progress was faster for the mainstreamed teenagers in the authors' study, suggesting that some aspects of their educational programme (for example, literacy activities and a range of curricular topics) or the speech and language environment (being surrounded by competent language partners) were beneficial.

Is there any evidence that therapy is effective in the teenage years?

There is little published information on speech and language intervention for teenagers with Down syndrome to guide parents, teachers or therapists beyond advice based on general principles and therapy experience. ^{[14,35,36,38]} There are very few studies which have evaluated the effectiveness of interventions. However, there is a study in progress with teenagers at the Waisman Centre, University of Wisconsin-Madison, which should shortly provide some valuable guidance on improving expressive language for this age group.^[45]

Teaching vocabulary

There is agreement among experts that the vocabulary of teenagers with Down syndrome continues to develop steadily, and that new vocabulary should be taught during the teenage years, but the authors are not aware of any published evaluation studies. The advice is to ensure that teenagers have the opportunity to learn vocabulary for age-appropriate interests, social and emotional needs, work and leisure needs and school curriculum topics. Vocabulary learning should be embedded into activities and contexts that are relevant and interesting for each individual. ^[5,14,15,40]

Communication skills

The use of language in everyday situations and the development of confident social communication at home, at school, with friends and in the community, usually develops steadily during the teenage years but most authors also recommend specific interventions. Such interventions may include role play (e.g. for social situations such as may occur in shops, buses, canteen, work place) including the use of video to enable young people to evaluate their performance and discuss how they can improve - as well as to record the success of their efforts.

Social conversation - greeting new people, making friends, joining in at the club, and being able to converse during coffee and lunch breaks at school, college or in the workplace - is an important part of daily life for adolescents and adults. Social embarrassment and, at worst, social isolation, are distressing and stressful experiences, but can be the consequence of poor social communication skills and may lead to avoidance or failure of social and work opportunities.^[14,19,28]

Speech and intelligibility

There is very little research on improving speech clarity available, yet speech intelligibility is felt by many to be the most disabling aspect of the speech and language difficulties of teenagers and adults with Down syndrome.^[14,19,28] Many teenagers are difficult to understand - their speech is not intelligible. Poor intelligibility can be the result of a number of factors, including phonology and articulation, pace of speaking, dysfluencies such as stuttering, and aspects of voice, including loudness, pitch and intonation.^[12,30-33]

Work aimed at improving phonology and articulation has only been evaluated for primary age children with Down syndrome.^[21,22] Most teenagers cannot make all the speech sounds and sound patterns in words as clearly as their peers, and there are published reports of progress for teenagers ^[19,56] and adults ^[20] from therapists.

The daughter of the first author was observed to improve her speech clarity throughout her teenage and early adult years. The first change was noted when she became a weekly boarder on a school programme at 13 years of age and was with adults and children who were not familiar with her speech - suggesting that the demands of the situation and the experience of not being understood successfully encouraged her to speak more clearly.

The general issue identified here is the tendency for family members and those familiar with a young person with Down syndrome to accept their poor speech, since they can understand it - but this does not help the young person to improve and bad habits may become established which are difficult to change.^[19,41,42]

The methods that have been used successfully with younger children are proposed as guides to working with teenagers.^[13,21,22] These are reported in full in the Speech and Language overview and summarised again at the start of the practical section on speech. In both these studies parents worked on activities with their children, guided by speech and language therapists. Phonemes that the children were finding difficult were identified and then worked on in words and as single sounds. The activities resulted in improved phonology and in longer sentences within 6-8 weeks.

Teaching grammar

The only published intervention study that has attempted to improve comprehension and production of more advanced grammar and syntax in teenage years is that of the first author.^[3,4] Twelve teenagers took part in a year long language teaching programme. Twice each week they had individual sessions in which they practised production of syntactically complete sentences. Each sentence was imitated twice - the student repeating it after the teacher. The student then repeated the sentence on his/her own twice more. Twelve different examples of the same sentence structure were worked through at every session. All the sentences were supported by picture illustrations to act as prompts. For half of the new sentence structures learned during the year, the written sentence was under the picture as an additional support during the training trials, to allow the effect of reading as well as listening to be evaluated.

Training began with sentences that the student understood but could not say in full - that is, the student would use the key content words and leave out the function words - ''He sit chair'', rather than ''He is sitting on the chair''. During the year, new structures were taught in comprehension as well as in production. All the training was audiotaped, transcribed and analysed to evaluate progress. At the start and end of the year, conversations were recorded with each teenager to see if any training benefits had transferred to their everyday spoken language. The teenagers enjoyed all the language training and were eager to come to the sessions.

In addition to the carefully organised repetitive practice of the sentence structures, examples of the structures being taught in this way were looked for in the student's everyday experience and language books were made. These books were illustrated with photographs taken as the students acted out illustrations of the sentences. For example, for sentences using 'above' and 'below' as new concepts, one student sat on a table and one underneath the table. They wrote in the book under the photo ''Julie is above Grant'', ''Grant is below Julie''. They then changed places and we photographed ''Grant is above Julie'' and ''Julie is below Grant''. In the same manner, we took photographs to illustrate comparatives ''Grant is taller than Shaun'', ''Shaun is shorter than Grant'', ''Grant is shorter than Stephen''...... and active/passive forms ''Shaun is pushing Grant'', ''Grant is being pushed by Shaun''.

To add to the language books, and to further support generalisation of the training to everyday use, we made conversation diaries to go between home and school. In these, the student decided what they would like to tell their family about their activities at school and this was written in the diary in the first person, to support narrative language (story telling or event reporting). For example, the student might write ''I cooked sausage and mash today with Julie. We went to the shops first to buy the food''. At home the student might write ''Last night I went to club with my friends'' or ''Tonight I am going to watch TV with my brother''. In school, the diaries were read out each morning during a newstime slot in class. At home and at school, parents and teachers were asked to read with the student as necessary, as some could not read independently. Some students could write and read their own sentences but most had to copy the sentences and needed support to read them correctly. Parents were requested to read with them and to help them to practise the sentences that they took home.

Tables 3, 4 and 5 illustrate that all the students benefited significantly from the training. This was demonstrated both in gains in the formal assessments of their comprehension and production and in the structure of their language in everyday conversations.

Table 3, the measures in Year 1 were taken to provide a baseline. No special intervention started in that year, so that the progress made between Year 1 and Year 2 indicates the progress that might be expected in a year due to increasing age and maturity. After the year 2 measures were collected, the intervention programme started and continued for a whole school year (September to the following July). The gains from Year 2 to Year 3 can be compared with the gains from Year 1 to Year 2, in order to see if the intervention aimed specifically at improving grammar had been effective.

The figures indicate that average gains of some 4 to 5 months on standardised measures might be expected each year, and that the intervention produced a significant additional gain in grammar comprehension and in sentence length in production. The increase in sentence length in the conversations of the teenagers was due to an increase in the use of :-

• grammatical or function words (articles, auxiliaries, prepositions and pronouns)
• word endings or bound morphemes (tense markers '-ing' or '-ed' and plurals)
• irregular past tense verbs

The figures in Tables 3 and 4 indicate a wide range of individual differences in the teenagers' progress. Unexpectedly, the 'least able' students benefited the most from the reading support (that is 'least able' in terms of the progress they were making on the school curriculum). They were found to be the students with the poorest verbal short term memory spans (digit spans of 2) and they simply could not repeat a six word sentence even when they had just heard it and had a picture prompt in front of them. However, they soon learned the printed words by repetition during the training sessions and used them to support correct practice. The students who could already read to a 7 or 8 year level, had longer digit spans of 3 or 4 digits (probably as a consequence of reading instruction) and could repeat the sentences correctly during training without the help of the printed version.

Gains in production over the year were affected by speech difficulties; those with the worst phonological or fluency problems made the least progress in production of sentences, though not in comprehension. The teenagers with the smallest digit spans at the start of the study also made slower progress in extending their productive sentence lengths. This could be because working memory capacity influences information processing ability as well as sentence planning and production.

Literacy activities and using computers

A number of authors have identified the importance of literacy activities for teenagers - both to increase their literacy skills and to improve their spoken language abilities. ^[23,24,25]

The Latch-On (Literacy and Technology Hands-On) programme of literacy developed at the University of Queensland for young adults with Down syndrome ^[23] is an excellent example of a comprehensive approach to the development of language, literacy and communication skills. Although it was implemented with young people who had recently left school, the principles are equally applicable to the secondary school age group.

In the teaching and learning activities, computers played an important role - being used to create texts and for email. Students did not have to have a specific level of literacy skill to be included. Significant use was made of photographs, to support story telling, description of events and story writing. Texts were created as joint and group activities, with peers and staff. Teachers would write for students whose writing skills were emerging. Similarly, reading text was a shared activity. The authors emphasise the importance of meaningful literacy activities - such as creating a newspaper together, keeping a diary, and writing a letter. They also found that a tape-recorder was a valuable aid for recording ideas for later text, for aiding memory and to provide feedback for improving oral language. The data being collected as part of this study indicates gains in reading, language and communication abilities.

The value of the computer as an aid to developing spoken language abilities was also demonstrated in the work of Laura Meyers in the USA.^[26,44] She worked with children from 18 months to 16 years of age. She identifies several principles behind her approach which are similar to those identified in the Australian study:

• scaffolding - the teacher works together with the pupil to extend the pupil's skills and enable him/her to complete a task
• continuity - learning must be built upon the pupil's well-established personal knowledge
• power - the intervention must empower the student to perform personally meaningful tasks

Meyers demonstrated the value of the computer as an aid to learning new vocabulary and learning grammar. She describes the power of speech from the computer in assisting children with Down syndrome to talk and extend their spoken language. She also emphasises the way in which written text makes the grammatical markers (such as word endings for plurals, possessives and tenses) and function words (articles, auxiliaries, prepositions) obvious visually, enabling children and teenagers with Down syndrome to process and learn them. In speech, these grammatical markers and words are not stressed and may be difficult to hear and remember.

There is now a considerable range of software available to support language learning and literacy development for teenagers. References to suppliers are included in the resources list.

The benefits of mainstream education for speech and language development

Recent research into the effects of inclusion in mainstream classrooms reports significant benefits for speech and language development. There may be a number of reasons for these benefits, including being with a peer group with typical speech and language skills for their age, receiving more intensive and individually tailored instruction and being involved in more intensive literacy instruction in mainstream classrooms compared with special education classrooms. These possible explanations will be discussed in more detail in relation to their practical implications later in the module.

In 1999, the authors and colleagues collected information on the progress of 46 teenagers in the county of Hampshire, UK, where the full inclusion of children with Down syndrome into local mainstream schools from 5 years of age began in one part of the county in 1988. This inclusion project was supported by charitable funding and inclusion did not begin at the same time in the rest of the county. This has enabled a comparative study of the progress of teenagers with Down syndrome, of similar abilities and family backgrounds, placed in full inclusion or in special schools, purely on the basis of where they lived. This study is reported in full elsewhere,^[1,2] but it is important to note that the teenagers in the two groups do not vary on any significant family or social variables which might affect their progress. Data was originally collected from 28 teenagers in special schools but to try to ensure that we were comparing young people of potentially similar abilities, the 5 least able teenagers from the special schools were taken out of the comparison group, before these figures were calculated and compared. The average age of the mainstream group is also two years younger than the average age of the special school group, which would reduce the likelihood of finding higher scores on any measures for the total mainstream group.

The data on the speech and language development of the teenagers is reported in detail for two reasons, to illustrate the effects of inclusion on speech and language progress and to illustrate the range of expected achievements. In this study, information on the speech, language and communication skills of the teenagers was collected using the Vineland Adaptive Behaviour Scale. This is a questionnaire and the information was provided by parents. However, the reader may wish to note that the same group of mainstreamed teenagers were assessed by a team of psychologists using standardised tests.^[27] The extent of the language gains for the mainstream teenagers was similar, when the Hampshire teenagers were compared with a different special school group in a neighbouring county, using different measures. This study is reported in the section on the 'Laws study'.

The Vineland Adaptive Behaviour Scale measures three main areas of development; Daily Living, Socialisation and Communication Skills. The Communication skills measure is made up of three component scores; Receptive Language, Expressive Language and Written Language (reading and writing). In Table 6 the scores for the Total Communication age are presented by age group.

The figures illustrate a significant increase in scores with age group and significantly better scores for the teenagers who have been in mainstream classrooms for all of their education. When spoken language and literacy skills are considered together, the teenagers in the inclusive school placements are more than 3 years ahead of their special school peers (despite the fact that the average age of the total group of included teenagers was two years younger than the average age of their special school peers). For the two younger age groups, the differences in Total Communication Ages are 2 years and 3 years 5 months.

Tables 7, 8 and 9 give the scores for each of the subscales that contribute to the Total Communication Score. The figures in Table 7 indicate that there were no significant differences in the receptive language abilities of the two groups - in other words, the language comprehension abilities of the two groups of teenagers are the same. However, the figures in Table 8 indicate that the teenagers in the mainstream classrooms have significantly better spoken language abilities. The expressive abilities for the total group are 2 years and 6 months ahead, and for the two younger age groups the differences are 1 year 5 months and 2 years 1 month. Overall, the older teenagers have higher scores than the younger ones suggesting continued progress with expressive language during the teenage years but, as this is cross-sectional (different teenagers in each age-group) not longitudinal data (same teenagers followed over time) it cannot be taken as conclusive evidence of progress with age.

The figures in Table 9 give the scores for Written Language, which includes reading and writing skills. It is clear that the literacy skills of the teenagers included in the mainstream schools are very significantly better than those of the teenagers in the special schools. For the total group, the mainstream teenagers are 3 years 4 months ahead (despite being on average 2 years younger). For the younger age groups, the differences are 1 year 2 months and 3 years 10 months.

The figures in Table 10 present the scores on the Vineland Communication Scales separately for boys and girls. For this group, the boys in the mainstream schools are significantly more delayed for Expressive language and Written language. However, the sample sizes are small and there is considerable variation in the achievement levels within each group, so that this result should be interpreted with caution. There is some evidence in the research literature to suggest that boys with Down syndrome, as a group, do have more severe speech-motor difficulties and that this could contribute to their expressive language and literacy difficulties. However, the reader should note that some boys will read and speak as well as the highest achieving girls.

Expressive language skills in more detail

Grammar

The next set of Tables (11 - 13) provides a summary of the data from individual questions on the Vineland Expressive Communication scale, to give an indication of the grammatical structures being used by the teenagers. The tables provide information on the percentage of teenagers using each grammatical word or structure. The figures in all the tables indicate that more of the teenagers in the mainstream settings have mastered more of the grammar and syntax of the language. However, there is still a significant proportion of teenagers in both settings who still cannot use a variety of basic grammatical words and structures in their spoken sentences i.e. they will still be using 'telegraphic' sentences and will benefit from the teaching of grammar.

Communication skills

The figures in the next two Tables (14 - 15) give an indication of the communication abilities of the teenagers. Table 14 is based on the Vineland Expressive Language Scale questions and it illustrates the effects of limited expressive language skills on the teenager's ability to share their life experiences with others. The ability to tell a story includes the ability to retell an event or experience. If you are not able to share your experiences with others then you may live in a rather socially isolated world, unable to share holidays, visits and interesting family events with others, or talk to others about experiences that may have frightened or worried you or that you just do not understand.

In the 1999 research study, information on the communication skills of the teenagers was also collected on a questionnaire designed by two of the researchers (Sacks and Buckley) for use in a similar research study conducted in Hampshire in 1986. In 1986, the families of 90 teenagers with Down syndrome were interviewed. At that time all teenagers with Down syndrome in Hampshire, UK, were educated in special schools. In Tables 15, 16 and 17 the data for the 1986 teenagers is included for comparison with the data for the 1999 teenagers. The Sacks and Buckley Questionnaire (SBQ) collected information across all aspects of the teenagers' development, practical skills, academic progress, health and social life, with only a small section focusing on communication skills. However, where the questions address the same skills, there is close agreement between the data from the Vineland and the SBQ. For example, similar to the Vineland Expressive Language findings (Tables 11, 12, 13), on the SBQ parents report that 83% of mainstreamed teenagers use grammar in their sentences compared with 52% of the special school teenagers (Table 15). In addition, on the intelligibility issue, the SBQ data indicates that the speech of the mainstream teenagers is clearer and that 78% are intelligible to people unfamiliar with them compared to 56% of those in special schools. This improvement in intelligibility may be due to two factors, clearer speech and better constructed sentences.

The data in Tables 15, 16 and 17 is based on the information provided for 18 teenagers in mainstream schools and 23 in special schools. The information for the five least able teenagers from the special schools is not included when comparing the two groups.

In Table 15, the vocabulary information indicates that 13% of the teenagers in special schools used less than 50 words or signs. Four of the five teenagers left out of the tables also used less than 50 words or signs. In total, this means that 15% of the 46 teenagers had very limited spoken language skills, using only one or two words at most to communicate.

In the section on sentences, the information indicates that 9% of the teenagers in special schools use only single words, 17% use mainly 2 or 3 word utterances when communicating, and a further 22% usually use 4 word utterances. This indicates rather limited grammar, and mainly 'key-word' or telegraphic sentences are used by 48% of the teenagers in special schools and by 17% of those in mainstream schools.

The activities provided in the practical section take account of this information, and cover vocabulary and grammatical development from the earliest stages, to ensure the needs of all teenagers can be met.

The section of Table 15 which considers the young people's ability to engage in a number of communication activities, indicates that the teenagers communication skills are good, in the sense that they all join in conversations, talk about past and future events, talk on the telephone and ask questions, even if they are doing so with only 'telegraphic' or keyword speech. This is an illustration of the specific language difficulty - all the teenagers wish to participate in a range of communication exchanges and will try to do so even if they only have limited spoken language skills. They still understand the purpose of a variety of communicative situations and do their best to participate in them.

The section on the use of signing indicates that, while over half (56%) of the special school teenagers are using signs, only 17% of those in mainstream schools are doing so.

Reading

The authors believe that the amount of reading instruction and supported reading activity experienced by the teenagers who have been educated in inclusive classrooms has had a positive effect on their spoken language and explains some of the difference in outcomes for the two groups.

A summary of the reading and writing achievements of the two groups is provided in Tables 16 and 17. The reader will note that, even after removing the 5 lowest achieving students from the special school group, 22% cannot read at all - not even their name - and, of those who can read (78%), only 39% can read more than 50 words. All the included teenagers can read, all can read their names, sentences, simple books and instructions. Parents report that 78% read for pleasure. This experience of reading may have helped the teenagers to expand their vocabulary and, in particular, to have given them extensive (daily) practice of 'talking' in grammatically complete sentences.

The letter/sound knowledge of the mainstreamed teenagers may also have had an important effect on speech clarity and their better intelligibility. All the mainstreamed teenagers know the names of all the letters of the alphabet, 89% know all the letter sounds, 78% can 'sound out' new words when reading and 72% when spelling. Knowledge of the letter sounds may have improved the included teenagers' ability to both hear the sounds in words and to say them. Knowledge of the written letters and their sounds also enables print to be explicitly used to support speech work.

USA study

The information on speech and language skills provided by the parents in this UK study is very similar to the information provided by parents in the USA in a comparable questionnaire study ^[42] in 1993. For example, some 84% of the 11-21 year olds in the USA study are reported to talk in sentences, and some 80% use articles in their sentences. Some 87% start conversations and 84% ask questions.

In the USA study, the parents were also asked about speech problems and 81% of the 11-21 year olds were reported to have articulation problems, 56% of the 11-16 year olds had stutters (23% of 17-21 year olds) and some 52% spoke too rapidly.

Only a small number of the teenagers were using signs - with only 8% using 50 or more signs. Some 80% of the teenagers could read more than 50 words and enjoyed reading. Some 40% were reported to speak more clearly when reading. Some 47% of the teenagers could 'sound out' new words using their phonic knowledge.

The authors of the USA study report that many parents felt that speech and language therapy and school assessments often underestimated their teenager's abilities, resulting in inappropriate targets being set for activities. This could reflect the fact that teenagers have been reported to have more confident and competent language in familiar settings such as at home and with familiar peers, compared with in the classroom. ^[43]

Laws study

This study^[27] involved a comparison of the language and memory skills of 22 children with Down syndrome in mainstream school placements in Hampshire and 22 children with Down syndrome in special school placements in a neighbouring county. (In the neighbouring county, all but 5 of the total population of children with Down syndrome were in special schools at the time of the data collection, while most of the children with Down syndrome in the study area of Hampshire were in mainstream schools. It is, therefore, likely that the two groups of children were of similar ability ranges when they entered the school systems at 5 years of age).

The children in the study ranged in age from 7 to 14 years and the data is presented for older and younger groups separately. The data for the older group only is discussed here as they are mainly of secondary school age, however, the pattern of results is the same for the younger group. In the older group the age range is 10 years 5 months to 14 years 10 months for the special school group of 11 children and 10 years 5 months to 14 years 8 months for the 11 mainstream children.

The average age of the 11 older special school children was 12 years 7 months, their mean score on the British Picture Vocabulary Scale (BPVS) was 3 years 5 months and their mean score on the Test for Reception of Grammar (TROG) was 4 years. The mean age of the 11 older mainstream children was 11 years 6 months and their mean score BPVS score was 5 years 4 months and their mean TROG score was 4 years 9 months. This study did not include a direct assessment of expressive language abilities although a sentence repetition task was included which taps both expressive language and memory skills, and overall, the mainstream children did significantly better on this task. The differences between the language comprehension scores for vocabulary (1 year 11 months) and grammar (9 months) are significant. This study included measures of auditory and visual short-term memory spans, and the mean span scores for the mainstream children (auditory digit span 3.20, visual digit span 4.20) were significantly better than the scores for the special school children (auditory digit span 2.42, visual digit span 2.58) ^{[27: p 452]}. This study does not present data on the reading achievements of the children, as the authors note that only 3 of the 22 special school children achieved a 'reading' score on a standardised reading assessment compared to 20 of the 22 mainstream children.

The teenagers with Down syndrome in the mainstream schools show a significant gain in language comprehension, short-term memory and reading skills but it is not possible to be clear about the inter-relationships. It can be predicted from research with typically developing children and children with Down syndrome that a gain in any of these skills would lead to a gain on the other two. For example, progress in reading will lead to gains in short-term memory and speech and language.^[16,53]

In summary

Most teenagers with Down syndrome will enter secondary school at 11 years with a spoken vocabulary of about 600 or more words and probably a larger comprehension vocabulary (words that they understand but do not yet use). They will be communicating in 'telegraphic' (keyword) sentences. They will not be using all the correct word endings (e.g. for plurals and tenses) or all the joining (function) words in their sentences. There is a wide range of individual variation and some teenagers will still have very small vocabularies of less than 100 words, and communicate in one- or two-word 'phrases'. Other teenagers will be fluent and using mainly complete sentences to communicate. The more delayed teenagers include those with the more severe hearing, working memory or speech difficulties. Almost all teenagers with Down syndrome understand more than they can express.

Many young people with Down syndrome of secondary school age will be difficult to understand until one gets to know them, as their speech is not clear - they still have some difficulties with speech sound production (articulation and phonology) and with organising and saying longer sentences (speech-motor planning). They are usually sociable and want to communicate, using speech and gestures or signs to do so. However, they may not be confident in starting conversations even though they join in when spoken to. They may also talk much less than most other young people of their age and this means that they are getting less practice at talking. They need practice at talking to improve their speech clarity, the length of sentences that they can use and their ability to use appropriate language in all social and learning situations.

This profile of development indicates that vocabulary, grammar, speech and interactive communication skills all need to be assessed and to be targeted with appropriate intervention strategies during the secondary school years. It is important that teachers and parents work together in assessing the children's skills and choosing targets. Ideally, a speech and language therapist, who is able to see the teenager, parents and teacher at least on a monthly basis, should guide them. However, as this level of speech and language therapy support is often not available, this module and the accompanying checklists are designed to enable parents and teachers to work effectively on their own, if necessary.

There is evidence that the speech and language skills of teenagers with Down syndrome do improve during the years from 11 to 20, and that the rate of improvement may be influenced by the quality of the language environment in school placements and by the quality and quantity of supported literacy activities in the school curriculum. There is some research evidence that targeted language work, designed to teach grammar, is effective for this age group.

In school, many of the speech and language targets can be met within the regular curriculum. New vocabulary can be learned during reading, maths and all topic work. Speech sound work can be linked to phonics and spelling activities. Daily conversations and interactions with other pupils and with staff provide opportunities to develop confidence in social communication, for example through sharing news, answering questions and discussing topics.

II. A programme of activities to improve the speech and language of teenagers

The advice and programme of activities recommended in this module are based on four sets of information:

• research into the processes and influences on speech and language development in typically developing children and teenagers
• research into the specific speech and language needs of teenagers with Down syndrome
• research into effective interventions
• the extensive experience of the authors and other colleagues from working with parents and teachers to provide interventions

A set of checklists, covering speech, vocabulary, grammar and interactive communication skills, is available to accompany this module. These checklists allow teenagers' skills in each area to be evaluated, activities to be targeted at the right level, and to provide a record of progress.

Some 11-year-olds with Down syndrome may be more advanced and already have many of the skills covered. However, we do advise that you complete all the checklists, in order to be sure that the teenager does have all the vocabulary, grammar and speech sounds in place. If they do, then speech and language development for them should progress from the everyday literacy and curriculum work in school.

All typically developing teenagers are learning new vocabulary and new grammar in school, mainly as a consequence of reading and writing, as required across the curriculum. It has been estimated that new vocabulary is learned at the rate of some 3000 new words each year from 7 to 16 years.^[16]

Very few children with Down syndrome have totally clear, fluent and grammatically complete spoken language skills at 11 years of age, so we expect most teenagers to need targeted speech and language intervention throughout their secondary school years. While we do not know how much we can improve speech and language skills in teenage years by specific activities, it is important that we do try, as the quality of life of many adults with Down syndrome really is substantially reduced by their speech and language difficulties. A team working with more than 1,000 adults in Chicago ^[28] reports that poor expressive language skills hamper the lives of the majority of the adults that they work with. In particular, they identify that many have speech that is only intelligible to families and carers in daily contact with them, so limiting work and social opportunities, and many are not able to express their emotions, worries and problems effectively.

The principles of the programme

The programme is based on two main principles: The need to improve the quality and quantity of everyday communication with teenagers, and the need to target the specific skills that underpin effective communication as many of these skills are areas of particular difficulty for teenagers with Down syndrome.

To maximise a teenager's speech and language progress both everyday communication experience and the teenager's underlying skills need to be considered at all times.

We then stress two additional principles: Firstly, the need, at all ages, to develop interactive communication, speech and language skills with clear targets for each, and secondly, the importance of keeping records of progress.

Improving everyday communication

It is essential that everyone involved with a young person with Down syndrome at home or school or in the community considers and, if necessary, improves the way in which they are communicating with and listening to the young person during ordinary activities.

Developing language is an everyday activity

Language develops because young people want to communicate and the single most important influence on the rate of progress in typically developing children is the quality and quantity of communication that the child or young person experiences throughout their day at home, at school or in the community.

Therefore, one approach to language intervention is to encourage everyone who is with a teenager to be sensitive to the way in which they communicate with him or her and to increase the amount of quality daily talk with the young person.

Improving the quantity and quality of daily interaction

Intervention programmes that focus on interaction and language aim to improve the effectiveness of parents and teachers as language teachers, during all their ordinary everyday communication with the teenager. Of course, many parents and teachers are excellent natural communicators and they adapt to the young person's needs without any further training. However, communication is a two way activity between partners and when one partner is having difficulty, and does not give natural, age-appropriate responses during the communication exchange, then it is not certain that all adults or other teenagers in the peer group will be able to adapt to their communication effectively without some explicit guidance. For example, research in classrooms with deaf children has shown that adults are inclined to be too helpful - and that when they change their style of interaction the language of the deaf children improves. The research showed that adults were inclined to finish sentences for children and ask too many questions, e.g. the child says ''went park'' and the adult promptly says ''Oh you went to the park did you? (child nods in agreement) ... Did you go with Grandad?'' - and the child nods again, with no need to talk further.

When the adults made a conscious effort to change their style of response, the length of the children's sentences increased. The changes were intended to encourage expansion by the child. For example the child says ''went park'' and the adult says ''Oh, that's interesting, can you tell me more'' to encourage the child to try to add information. The adults were also reminded to be patient and to be good listeners. If this study had been done in the classrooms of children with Down syndrome, the authors feel sure that the results would be the same.

The natural reaction when talking to someone with speech and language difficulties is to help them in order to make the communication a success - but, in fact, these 'natural' reactions may hold back the young person's progress. In addition, the authors have observed that, if a teenager's words are unintelligible, the conversation partner may need to ask the teenager to repeat the words, to be sure that they understand what the he/she is trying to say, before they can respond. This disrupts the normal flow of the conversation and the partner's ability to respond to the communication by replying in a natural way.

These examples illustrate that when a teenager has even one area of delay or difficulty in her/his speech and language skills, this will almost certainly reduce the quality and quantity of natural talk to and with him/her, in comparison with a typically developing peer. Yet the teenager with difficulties needs more good quality language experience and learning opportunities than the typical peer in order to make progress.

In the mainstream secondary school classroom, a teenager with Down syndrome will talk less than most of the other teenagers, and initiate fewer conversations.^[34] This means less practice at talking, which will reduce opportunities to practise planning and producing words and sentences (using grammar) and reduce speech practice (using articulatory and phonological skills). In typical development all these skills improve with practice through the school years, as young people talk naturally every day.

The importance of preparation

The first requirement for any parent, teacher or learning support assistant using this programme is that you become familiar with the stages of speech and language development in typically developing children and with what is currently understood about the processes that influence their rate of progress. In particular you should be confident that you know what skills and style of communication will make you a good communicator. You can do this by reading the overview module in this series. You can also do this by learning from your local speech and language therapy service or from going on an appropriate course.

The second requirement is that you should then take time to consider how you are currently communicating with your teenager with Down syndrome - and how he/she communicates with others - at home or in school (in and out of the classroom) and identify ways in which you could improve either your style or the quantity of communication experience that you are offering him or her.

The third requirement is that, as you read in the next section about the additional ways that you can help your teenager, you remember that they are additional, they do not conflict with any of the principles which make you a good communicator. Some require that you to try to absorb them and use them in all your everyday interactions to make all your communication with your teenager more effective (for example, speaking clearly, reducing background noise, maintaining eye contact, using signs). Others require some time to be spent each day on extra teaching activities. At home, try to absorb some of these activities into times that you already spend with your teenager. Others can be included in no more than a half hour session each day of planned language or reading activities with your teenager (or two 15 minute sessions). In school the teaching activities can be easily absorbed into the current curriculum in the classroom. Fifteen minutes of planned speech and language activities daily really will make a difference - and will be more effective than an hour twice a week.

Targeting the specific profile of needs

As has already been stressed, young people with Down syndrome usually experience considerable delays and difficulties with learning to talk.

Current research (described in Speech and language development for individuals with Down syndrome - An overview), identifies a common profile and some of the causes.

Most children and adults with Down syndrome understand more language than their expressive language skills suggest and therefore their understanding is often underestimated. Their social interactive skills and non-verbal communication skills are a strength but speech sound production (articulation and phonology) is a specific weakness. Vocabulary learning, while delayed, is also a strength but grammar learning is a weakness, so that the children tend to talk using keywords rather than complete sentences.

Children with Down syndrome show the same progression from one word to two word combinations when they can say between 50-100 words as other children, and they show the same progression to early grammar in their speech when they have a spoken vocabulary of 300-400 words. Unfortunately the usual delay in reaching a productive vocabulary of 300-400 words (at 5-6 years or later, instead of at 2-3 years) may compromise the ability to master fully sophisticated grammar and phonology in later speech.

Progress in comprehension and production of vocabulary is almost certainly affected by hearing difficulties. It is certainly delayed by the children's specific difficulty with speech sound production. Progress in sentence production and in later grammar learning is also delayed by a weakness in the auditory or phonological short-term memory system.

This profile of strengths and weaknesses identifies that any remedial programme needs to aim to:

1. Reduce the effects of hearing loss by:
   1. Regular hearing assessments and prompt, effective surgical and/or medical treatments
   2. Reducing background noise, speaking clearly and maintaining eye-contact while speaking
   3. Using compensating strategies in the teenager's communication environment which make maximum use of visual supports (signs, pictures, print)
2. Improve articulation and phonology by:
   1. Encouraging control over oral motor skills
   2. Building up sound discrimination and production skills
   3. Practising single speech sounds
   4. Keeping a record of the teenager's speech sound skills
   5. Practising whole word and sentence production
   6. Using signs and reading activities to support speech sound work
3. Accelerate vocabulary comprehension and production by:
   1. Teaching a target vocabulary
   2. Keeping a record of the teenager's comprehension and production of words
   3. Using an augmentative communication system, usually signs, to support comprehension and production of words
   4. Using reading activities to support the comprehension and production of vocabulary
4. Accelerate mastery of grammar and sentence building by:
   1. Encouraging the use of complete sentences
   2. Teaching the grammatical markers (bound morphology)
   3. Teaching word order rules (syntax)
   4. Teaching function word grammar (closed class grammar)
   5. Keeping a record of the teenager's comprehension and production of grammatical markers and sentences
   6. Using reading activities to support the comprehension and production of grammar and sentences
5. Take account of the auditory short term memory weakness by:
   1. Improving sound discrimination and production skills
   2. Practising words to improve the stored sound patterns
   3. Playing memory games
   4. Supporting learning with visual materials, pictures and print, to reduce memory requirement
6. Capitalise on the teenager's good social interactive skills and develop them by:
   1. Being sensitive to all the teenager's attempts to communicate, verbal and non-verbal, by listening and responding to them
   2. Creating opportunities for the teenager to make choices and to express him/herself through language
   3. Encouraging the use of gesture to communicate as it is a strength and may be important throughout life for some individuals
   4. Remembering to listen and to wait to give the teenager a chance to organise their contribution to the conversation
   5. Using styles of conversation that encourage the teenager to expand on and develop their contribution
   6. Providing as many social opportunities as possible for the teenager to be able to communicate with and learn from other non-language delayed young people and adults in ordinary classes, around school, clubs and social activities.

Working on speech, language and interactive communication skills in parallel

Whenever we communicate we are using our speech, language and communication skills simultaneously, therefore at any age an effective speech and language therapy programme needs to consider the teenager's strengths and weaknesses in each area. The programme should then work on each skill area as necessary, in parallel, rather than concentrate on language learning and neglect speech, for example.

Recording progress and planning

We believe that it is important to keep records of the teenager's progress as this:

• encourages careful observation and an accurate knowledge of the stage the teenager has reached in each area of development
• provides a record of progress and achievements
• provides a guide to the next skill or step forward that is to be expected, allowing you to choose the next activity to focus on with confidence that your teenager will be ready for it
• ensures that the teenager's skills are not underestimated
• keeps parents and teachers on task and motivated.

We do not wish to impose too much extra work for families and teachers but the evidence does suggest that speech and language skills need additional targeted help and that most teenagers and adults with Down syndrome could be talking more and talking more clearly if we take relatively simple but planned steps to help them.

Learning to talk is the most important thing that children do. It is central to all other aspects of their development. It is critically important for social and emotional development and for the development of cognitive or mental abilities, so progress with learning to talk will benefit every other aspect of a young person's life.

Using the DownsEd checklists

Down Syndrome Education International has developed a set of checklists which may allow you to evaluate your teenager's current speech, language and communication skills and to record future progress in a simple and straightforward manner. The checklists cover interactive communication skills, speech sound skills, a core vocabulary and sentences and grammar.

The checklists will not be relevant for all teenagers, as those with more advanced speech and language may already have a large vocabulary and most grammar in place. However, we suggest that you do take a look at them, as the majority of teenagers will not have progressed beyond the range of skills covered by the lists.

For vocabulary, three lists are provided to take your teenager to an 800-word core vocabulary in stages, the first 120, then the next 340 and the remaining 350. The words chosen are based on research on the order in which children learn words. The third list also includes the key vocabulary required for reading and for number in school and the words needed to develop more advanced grammar and sentence structures. Research evidence indicates that a 250-300 word vocabulary is necessary before grammar will develop.

However, the severity of the learning difficulties of young people with Down syndrome varies widely, therefore what really matters is that your teenager is progressing, even in small steps, and that communicating together is enjoyable and effective.

The Speech sounds checklists and record sheets cover all 44 single sounds (phonemes) used in English and the common blends and clusters. The Sentences and grammar checklist gives examples of the two and three word combinations that young people may use before they can produce complete sentences and then provides a guide to developing grammar.

The Interactive communication and play skills checklist provide a guide to the range of communicative functions that young people use, and to their ability to join in and initiate conversations.

Parent/teacher collaboration

It is a great advantage if parents and teachers can work together to complete the checklists. Teenagers may use different language at home and at school, therefore observation records should be kept for a week or more by both parents and teachers (or support assistants) and then the records shared in order to complete the checklists and choose targets. Talking is a continuous activity during waking hours, and parents have as much opportunity to help their young person to develop spoken language skills as teachers, so working together is the best way to help the individual.

Keep an observation diary

Before you start choosing activities from those given in this module, we suggest that you observe your teenager over the next few days (at home if you are a parent, in school if you are a teacher or support assistant) and note down the gestures, signs, words and sentences that he/she is already using to communicate. If your teenager is joining words together, then note down the words and sentences that he/she is using during the day.

Keep an observation diary close to hand and write the words down just as they are said - for example, ''juice, mum'' or ''go school bus'' or ''me car''. Make a note of the range of communication that your teenager engages in, for example, showing, asking, refusing or greeting. You will be able to use your observations to complete the checklists and decide on the correct targets for your teenager, and to note progress over time.

Remember we are all experts at language

The checklists and all the information in this and the overview module may seem daunting. When we analyse how we learn to talk and break it down into interactive skills, sounds, words and grammar, we make it seem complicated. We hope that the detail does help you to understand all the skills that your teenager is mastering step by step - but do remember that you are a competent talker and communicator and that you do use all the grammar described and the speech sounds, naturally. When some of the ideas seem difficult, just think about how you talk and you will see how you use tenses, prepositions and pronouns and auxiliary verbs, for example, without usually having to think about them.

Getting started

The activities are set out for each area of development starting with interactive communication skills, gesture and sign, then speech, vocabulary and grammar. In each area, activities are recommended in developmental order, so remember to identify your own teenager's achievements in each area and choose activities to help her/him to progress in each area.

You do not need to read the whole of the module and take in all the advice and ideas at once. Start by completing your observation diary and the checklists. Then read in each section, the ideas and advice that will provide activities for the next steps, based on your teenager's current level of progress.

Integrating targets

You are encouraged to choose targets for speech sound work, for new vocabulary, new grammar and for communication skills. However, please note that these targets can often be integrated into one activity - for example, making a book on a topic which includes new vocabulary, the sentences and grammar, and words with the speech sounds and/or the number of syllables you wish to practise. The topic book can then be used as a conversation diary to enable the teenager to share an interest or event with his/her peers or family. This activity may also encompass or be linked with the literacy targets for the teenager.

Interactive communication

Interactive communication skills are usually a strength for teenagers and adults with Down syndrome. Most teenagers and adults want to communicate and to participate in social situations. They use and understand the non-verbal communication skills that everyone uses including eye-contact, smiling, turn-taking, facial expressions, body posture, tones of voice, and gesture, to communicate and to support spoken communication. They also use both verbal and non-verbal skills for the same range of communicative functions as everyone else (i.e. asking questions, answering questions, requesting, giving information, commenting, expressing feelings, greeting, drawing attention to self), even though they may not be able to express themselves as fluently in speech as their non-disabled peers.

Interactive communication skills include all the non-verbal skills identified, which are used throughout life, and they include the conversational skills that develop later as young people become competent talkers, such as taking turns as listener and speaker, telling stories and initiating conversations with visitors.

It is important to encourage all forms of communication because non-verbal skills, including gestures, support spoken language and also because some teenagers and adults with Down syndrome may need to use signs to communicate effectively, especially if they have difficulty developing clear speech.

The Interactive communication and play skills checklist provides some guidance to the social interactive uses of language.

Non-verbal communication and signing

Research studies have shown that signing acts as an important bridge to speaking for individuals with Down syndrome. They learn to understand and to use new words faster if they are accompanied by a sign or a visual cue and, in addition can often sign the word spontaneously before they can say it.

In the authors' experience, most young people with Down syndrome will not need to learn more than 50 to 100 signs before they are moving on to using words as their main means of communication. As they can begin to say a word, they usually drop the sign for that word and use the spoken word. This should be encouraged, as the spoken word will only become clearer with practice. However, sign can still support the learning of new vocabulary, as we know this will speed up learning to understand and use the new words.

The use of sign during the teenage years

By eleven years of age, the amount of signing a young person needs will need to be judged on an individual basis. Most teenagers will be using speech confidently as their main mode of communication, but others (about 10%) will still be dependent on signs and should be taught new signs. The critical issue will be the young person's speech sound skills and spoken language; those with better sound production skills will be talking and those with more sound production difficulties and restricted vocabulary will need more signs. A speech and language therapist will be able to advise, but it is essential to take a careful look at the use of signing for each young person. Speech is difficult for individuals with Down syndrome and their speech will only become clearer if they practise speaking. However, being able to be understood using signs may reduce the need to improve speech clarity and delay improvement in intelligible speech.

The issues are complex however, as research and personal experience indicates that some teenagers and young adults with Down syndrome speak more clearly when they sign at the same time.^[54] This may be because recalling signs is easier than retrieving spoken words for these young people, therefore the signs actually help them to retrieve the words and say the words in order.

We suggest that parents may be the best judge of the sign/spoken word balance as they will know how best their teenager learns to understand new words and how best he/she communicates in everyday situations. Only a small number (5 - 10%) of teenagers with Down syndrome will require a signing environment, where all spoken language is supported by signing, in the long term.

Conversational skills

Initiating and responding

We need to consider the way teenagers are joining in and also starting conversations. If you ask a question, does your teenager respond? Does your teenager comment on things that he/she sees when you are out? Does he/she ask questions? Does he/she join in family conversation at the meal table? In school, does your teenager ask questions, contribute in class or start conversations with friends? Can he/she discuss worries with you? Does he/she start new topics in conversation? Does he/she relate events that have happened at school or club to you?

If not - is it possible to think of ways to include your teenager in school and family conversation and encourage him/her to ask questions? Initially, you may need to draw him/her into conversations by asking questions and then giving your young person time to answer, followed by comments like ''that's interesting'' - and ''what else happened?'' or ''can you tell me more?'' You may need to take turns around the table, as this will provide your teenager with model sentences to copy and support him/her in taking a turn in the conversation.

Encouraging narratives

Research has shown that teenagers with Down syndrome often use longer sentences (i.e. better language) when telling stories or relating events than when answering questions. This suggests that it is important to encourage 'story-telling'. Providing teenagers with picture prompts such as postcards or photographs will help them to share their experiences and relate events to their friends or to members of the family. Helping them to make books about their favourite pop stars, sports interests, holidays and school projects will also provide them with 'props' to talk about their interests with others.

Be a good listener

Being interested in teenagers' activities and being a good listener will really help in encouraging them to talk and to share their experiences. However, it is not easy for young people with Down syndrome to become fluent and confident in social situations and they do need thoughtful and sensitive encouragement in order to join in and initiate conversations.

Increasing the quality and quantity of language experience

Increasing the quantity of language use and experience as well as the range of useful phrases that your teenager can use is important. If you observe your teenager at home, in a social situation or in the classroom, how much does he or she talk compared to other young people of the same age in these situations? It may not be easy to increase this, but it is important to try. At school, make sure your teenager takes full part in 'social times', taking his or her turn with whatever support is necessary, such as the books and photos suggested to help the other young people to understand, or the use of a conversation diary for support (see later in this document for a description of conversation diaries).

Include the teenager in answering questions during lessons and in conversations during group work around the table. Remember that the other teenagers will act as models for the language needed to talk in the classroom, so turn taking with other teenagers will be valuable. It is important that the other young people fully understand the difficulties of the teenager with Down syndrome in the class, and in the school, and that they are encouraged to be sensitive, to listen and to include him or her in their activities. Explain to the other young people how they can help by taking turns, modelling sentences, being sensitive and taking time to listen.

It is important that both adults and peers do not become too helpful and talk for the teenager with Down syndrome or jump in to prompt him/her too quickly. Remember, it will take your teenager with Down syndrome longer to organize what he/she wants to say.

The social use of language

Teenagers with Down syndrome may need help to learn the language for opening a conversation such as ''Hello, Mrs Andrews'', ''Hello Susie, where have you been/did you have a good time?'', ''This is a delicious cake Gran'', ''May I have a drink/watch TV please?'', ''Thank-you for the disco, I've had a great time'', ''Thank-you for having me to visit/for sleep over'', ''Where's the toilet?'' Meeting strangers for the first time phrases such as ''Hello, I'm Julie. What's your name?'', ''Hello, have you come to see Mr Green? Can I show you the way?'', ''Hello, I'm Julie and this is my sister Sally''. We all use 'openers' like discussing the weather, asking about the journey someone has made, where they go to school, and other non-intrusive conversation starters.

The most effective way to learn these social sentences may be to write them down on cards, which can be used to support practice and can be used in the real situations while the teenager is learning.

Behaviour and communication

Communication in lessons and elsewhere can be a problem and lead to behaviours, often disruptive behaviours, as the young person's only means of communicating. Some of the behaviours that seem inappropriate in teenagers at school may be used because the teenager cannot say what they want or what the problem is.

If a teenager has only limited speech and language, then he/she may not always be able to explain their difficulties in words, so 'act them out'. For example, other teenagers crowding them in the breaks, or being over anxious to help them can occasionally lead to a teenager with Down syndrome pushing or seeming to hit out at their classmates. In the classroom, a teenager may become 'stubborn' because they cannot say ''This work is too difficult, can I have some help please?'', or ''I am hot/thirsty/have a headache''.

You may need to model, expect and prompt socially appropriate language at a level your teenager can master, for example ''leave me alone, please'' or ''I do not need your help'' instead of ''go away'' or pushing. Sometimes, other teenagers lead the young person with Down syndrome into trouble by encouraging them into inappropriate behaviours but the young person cannot say ''Terry told me to do that'' or ''Sally took that bag, not me''.

In the classroom phrases such as ''I need help please, Mrs Jones'', ''Can I go to the toilet, please?'', ''What are we going to do after break?'', ''Where is my maths book?'', ''I cannot do this, it is too hard'', ''I do not understand this'', ''May I work on the computer please?'', ''Can I read a book now?'', ''I have finished my work'', ''Is it lunchtime yet?'', ''When do we go home?'', ''Where are my shoes?'', ''Please help me with my shoelaces'', ''I'm too hot'', ''I'm cold, may I get my coat/jumper/sweater please?'', ''I feel ill/poorly/sick'', ''I have an earache/stomach ache/headache'', ''I have a 'period' pain'', ''I'm tired/thirsty'', ''I'm thirsty, may I have a drink please?''

Some of these sentences may seem much too difficult for your teenager at the moment but write them on cards as appropriate and help him/her to use them. At first your teenager may be able to choose the right card because they can recognise one keyword on it or you could put cartoon drawings to help - but this might deter your teenager from learning to say the actual words, so only use pictures to get started. Remember to model (say) the sentence so that your teenager can copy you, both at home and at school.

Social scripts or stories^[4] are written scripts that can help teenagers to understand what is expected of them in social situations and at school. For example, ''In assembly, a Year 7 pupil is expected to sit and listen quietly. First we sing and then the Headteacher will talk to us. After that we go back to our class''. ''When the bell rings, you should go to your next class. If you can do this on your own, Mr Brown will be very pleased''. Sometimes we forget that, although we reprimand teenagers for behaving inappropriately, no one has made sure that they know what behaviour is actually expected of them. This issue is discussed in more detail in the social development module, with further examples of social scripts.

Expressing emotions and feelings

Teenagers with Down syndrome are usually socially sensitive; they understand other people's emotions and show appropriate empathy. However, they may be picking up mainly the non-verbal cues we all use to identify emotions, and they may not have an adequate vocabulary of emotion words to be able to explain how they feel or to ask others about their feelings. It is therefore important to ensure that vocabulary targets include words for everyday emotions such as happy, sad, excited, frightened and angry.

In teenage years, relationships with special friends and boy/girl friends become important. Teenagers experience strong emotions and sexual feelings during this time and it is important that they are helped to understand these. They will need to learn appropriate vocabulary and appropriate ways of expressing themselves. Parents and teachers need to look for suitable picture materials to aid the understanding of young people and they should not shy away from this area of development. Teenagers need to know what behaviours are appropriate and how to handle 'crushes' and 'rejections'. These experiences may be more painful in inclusive school settings, if there are no other disabled peers to share 'growing up' and to provide reciprocal, mutually supportive, close friendships,

Speech and speech intelligibility

Most teenagers with Down syndrome of secondary school age have some delays and difficulties in developing clear speech. This can be very frustrating for them as it means that their speech is often not understood. Speech difficulties hold back the teenager's ability to say sentences and to develop grammar, therefore speech work should be a priority in the secondary school years, at home and at school - and can be built into reading and spelling activities.

Research indicates that, for teenagers with Down syndrome, speech intelligibility difficulties result from difficulties at every stage of speech production.^[30,31] Teenagers have difficulties with the articulation of single sounds, with phonology - the production of the range of speech sounds, blends and clusters in the language, with producing clear words and with producing clear sentences. The production of sentences requires retrieval of words and grammar, and speech-motor planning.

Experts agree that there is evidence of difficulties at all these levels and therefore we recommend activities for each level from sounds to sentences.

Much more research is needed into the speech production difficulties of children and teenagers with Down syndrome, but recent research draws attention to the inconsistency in their production - that is, the same sound produced with a range of different errors on different occasions and correct in some words but not in others.^[13] We suggest this fact is used to plan practice by choosing words in which the teenager can say the sound correctly to practise with words in which they are not yet producing the same sound correctly, e.g. ''ball'' is clear but ''button'' is said as ''tutton''. Write both words and show the teenager the b in each, to support correct practice. This example could be used in a ladder game - see Figure 1.

Researchers have also suggested that poor production of words may be the result of poor storage of the phonological or sound pattern of the word,^[13,40] so that the teenager does not have an accurate specification of the word in memory from which to organise correct production. This is a very plausible hypothesis given evidence for significant phonological loop impairment in children and teenagers with Down syndrome which would cause exactly this problem.

Further, there is evidence that the planning and processing needed to produce a clear string of words as a sentence overloads the working memory and cognitive processing capacity of many young people with Down syndrome. They can do part of the task well, e.g. produce two or three words clearly, but not a sentence of six or seven words - and they can usually read with much greater clarity, fluency and even intonation than is evident in spontaneous speech. When reading, the teenager is not required to think and to plan his/her sentences in the same way as in spontaneous talking.

If we identify targets for speech work at each level - and make maximum use of reading activities to support spoken practice, we should be able to significantly improve speech clarity and sentence production for most teenagers. We have incorporated the principles of the therapy approaches shown to be effective with younger children with Down syndrome into the activities. These are summarised in the boxes.

The advice in this section starts right at the early stages as some teenagers with Down syndrome will have had no speech work in primary school and a small number may still have immature feeding, chewing, breathing and drinking skills. Research indicates that 16% of teenagers still have difficulty with chewing, 18% with swallowing and 25% with tongue thrusting.^[51]

Skills that affect speech

Many aspects of children's development will have an influence on speech skills, including breathing, feeding and drinking skills and general motor control. It is important to encourage good feeding, sucking, chewing, drinking and breathing. The coordination and control of the movement of lips, tongue and breathing needed for chewing and swallowing develops similar actions that are needed for making clear speech sounds. Most 11 year olds will be chewing ordinary foods and drinking normally from cups but some will have extra difficulties, and if your teenager is delayed then feeding and drinking skills need to be addressed.

It is important to steadily move your teenager on to chewing lumpy foods, just increasing the texture a little at a time until he/she can chew ordinary pieces of food. At the same time, if necessary, move your teenager to drinking from a normal cup in stages, using a cup with a spout, then a recessed lid and finally an ordinary cup. Watch that your young person keeps her/his tongue inside the mouth when drinking, and does not put her/his tongue down the outside of the cup. Encourage your young person to learn to drink from a straw. The special straws, with built-in valves, sold in the pharmacy for those with difficulties such as stroke patients, can help. Small drink cartons with straws can also be used to assist young people to learn to use a straw, by squeezing the carton to send liquid up the straw. Encourage bubble blowing and whistle blowing games to get your teenager to make a round lip closure.

Encourage mouth closure and nose breathing as much as possible. Games to encourage lip closure and breath control include blowing through a straw to move pieces of foil, tissue paper or small balls and blowing pipes and whistles.

Your teenager's gross motor development, including head and trunk control and muscle tone, will also influence his/her ability to control breathing and face, mouth and tongue muscles. Being involved in physical activities and sports will improve general motor development and breathing.

Speech sounds

Activities that encourage the young person or adult to practise their sound and word production are effective for improving speech into adult life. Speech is a motor skill and, like other motor skills, will only improve with practice. Teenagers with Down syndrome, because of their language delay, will have had much less practice at talking than their peers and this may explain at least part of their speech difficulty.

Speech and language therapists in all countries have access to pictures, other materials and activities aimed at improving phonological awareness and speech production, although they may not know that these activities, designed primarily for children with speech and language disorders, are also appropriate for teaching teenagers with Down syndrome. They may also not know how important it is for teenagers with Down syndrome to continue learning through extra practice in secondary school. Cued articulation^[47] and the Nuffield Centre Dyspraxia Programme^[48] are examples of this type of work. These and other programmes may not always be suitable for every teenager though, and do require the guidance of a trained professional to advise when and how to introduce activities. If there is no speech and language therapist available however, parents and teachers can do much to help teenagers improve their speech using readily available materials and activities.

Development of sounds

For all young people, spoken words become more intelligible with increasing age and use of their language skills. Achieving intelligibility takes a number of years, even for young people who do not have specific speech and language disorders or delays.

Many of the speech difficulties noticed in young people with Down syndrome are part of the normal development of phonology (see box) ^[37], and will improve, provided the young people have sufficient practice through talking and using their skills. Studies report inconsistent production, that is, the teenagers may be able to say a sound on one day and not the next, and more practice and feedback over many months may be needed to establish consistent production. First attempts at words may not even be close approximations and so any attempt should be encouraged.

While lack of confidence can contribute to slow progress, it is more likely that an unresponsive teenager cannot remember or cannot produce the sounds without a prompt, even though he/she may recognise it when it is said and can imitate it, rather than he/she is being deliberately resistant to producing the sound.

Never let your teenager feel that they have disappointed you or place them under pressure to produce sounds or words.

Practice for speech sounds

Letter sounds

As teenagers progress in their language knowledge and skills, phonics materials which teach letter sound recognition for reading can be used. This will help to link their speech and language activities to their developing or established literacy skills. Some teenagers with very little speech who are still experiencing difficulties with single sound production may find it easier to get started with picture materials rather than letter cards. Vowel sounds in particular may need picture supports as well as letters to facilitate practice.

Computerised systems are also available as a complementary way of enabling teenagers to practice sound production, for example, SpeechViewer III.^[49] This laptop computer version provides visual feedback so that teenagers can see how close they are getting to making a sound accurately. When they have made the right sounds (or series of sounds, or pairs of sound contrasts like 'sh' and 's') they are visually rewarded for doing so. There are visual incentives that help to speed up the saying of single sounds in a series of repetitions, for example, with a frog jumping from lily pad to lily pad, every time a sound is said. The Speechviewer also has facilities for encouraging many other aspects of speech development, as well as phonology, including voice, pitch and control of breathing. Ideally, SpeechViewer should be used with the advice of a speech and language therapist. Teenagers unable to make a particular sound may need a speech and language therapist to show them how to make those sounds.

Improving sounds in words

Repeating the words that teenagers say so that they can hear them correctly spoken, and encouraging them to imitate, will develop their speech clarity. Be careful not to criticise though, as this may discourage your teenager. Repeating single words back on every occasion may distort the flow of conversation; so try to feed back the correct production of a word in a natural way. For example, when a teenager has asked for a 'coke' by saying 'coe', you might say, ''yes, let's get a coke'' (emphasising the word the teenager said, clearly and quite loudly) or ''McDonald's, that's right, we are going to McDonald's'' (again emphasising the correct pronunciation of the word). If words lose their communicative value, and the focus is totally on clarity of production in all situations, this could deter some teenagers from talking.

When teenagers talk and are given feedback in this way, they will continue to develop their phonological system and improve their speech. This is likely to be accelerated when they have been introduced to literacy teaching and if they are in a good language learning environment at home and school.

But, for the majority of teenagers with Down syndrome, ordinary communication experience alone is not sufficient to lead to the development of clear, intelligible speech in adult life, and they can be helped to progress more quickly by focused practice on single sounds, series of single sounds, series of varied sounds, sounds in words, pairs of words with contrasting sounds and additional practice for joining words together in longer combinations.

Practice sessions that are focused on improving phonology and speech production have an advantage over practice during everyday communication, in that the teenager and parent both know that the activity is about how you say the word and it focuses their attention on phonology. When a word can be said in a practice session, then it can be generalised to everyday language, with activities designed for this purpose.

Choosing sounds and words to practise

In order to speak clearly, teenagers have to be able to say single sounds, then to join sounds together in a variety of ways to produce clear words of one or more syllables and string words together to produce sentences. At each step, the speech-motor planning and control required increases. Most teenagers with Down syndrome will be helped by activities for each stage - at the sound level, the word level and the multi-syllable, multi-word or sentence level.

For teenagers who are not able to produce the full range of sounds, words that contain sounds that they can say can be targeted for practice, as these are more likely to be achieved. You can use the vocabulary checklists with this module to choose words to try with them.

Speech and language therapists are able to listen to teenagers' speech or look at records of words they can say, and make suggestions for therapy, to move them forward gradually and with success, without asking them to say words that are just too difficult at that stage in their speech development. Of course young people need to practise difficult words and phrases too, and need to be gently encouraged to do so all of the time, but targeting a set of words closer to their current skill level will help them to be successful and to gain in confidence.

Without a speech and language therapist to help guide and structure the practice, we advise parents and teachers to use the speech sounds and vocabulary checklists to guide the selection of sounds and words for practice and to record progress. The sound list will help you to choose sounds for sound games and the word lists indicate words that your teenager can attempt but not yet say clearly.

Games with individual sounds

Practising with individual letter sounds in games, and speeding up a teenager's ability to accurately produce sounds is good practice. Practise letter sounds you are working on (not too many at once) and also practise words (with pictures) beginning with the same letter sounds as a complementary activity. Do not wait for all consonant and vowel sounds to be achieved before practising words, but choose words that contain some of the sounds your teenager can say.

Practising words that are important to the young person will help her/him gain some control over daily events. Words that your teenager wants to use to request and comment will be learned the fastest. Next, choose topics of interest to expand vocabulary such as sports, pop music, TV programmes or a project in progress in the classroom. Scrap books can be made with pictures and words as an aid to support practice and make it interesting.

The THRASS reading and writing system^[50] teaches groups of letters that make the same vowel sound and is good for teaching all speech sounds to older children.

Various 'ladder' games (see Figure 1) made with pictures and letters can be used to encourage teenagers to practice single sounds repetitively, and the same technique can be used for whole word practice or contrasting word practice. Where teenagers are familiar with formal literacy work, printed ladders of various types can be used, for letters or words, as illustrated.

Choose words with one letter sound targeted in one position

For example, choose a list of words that all begin with the same letter. Picture dictionaries or books that have vocabulary items listed alphabetically are useful for this, as they will provide a list of personal-interest words all beginning with the same sound. (When choosing words, please note that clusters such as 'sl' or 'tr' need to be practised separately and are not suitable for practising the single sounds 's' or 't'.) Work through groups of words beginning with different letter sounds that you are targeting for practice.

At this stage you will know which sounds in words, at least in the initial position, are difficult or easy for your teenager to say, as well as how easily he/she can say sounds in isolation. You might choose to put a difficult word in with a list of easy words for your teenager to practise, to encourage them, and as you get more practised and your teenager more confident, you can choose words that really target your teenager's particular difficulties. If you listen to your teenager carefully, you will notice what some of their difficulties are, but you will need to break up words and design activities that are at the easiest level you can think of, and that you can build up later on, so that practice items are not so difficult that they are discouraging.

Joining sounds for words and syllables

Joining one consonant to one vowel, as in 'key' or 'see', is easier than saying words with more sounds in them (cat, brick, slip) or a multi-syllable word, where many changes in position of the tongue, lip and soft palate are needed to make the word. (The soft palate closes so that air does not go down your nose, as in 's' and 'sh' words, and opens so that it does come down your nose a little, when you say 'm' and 'n'). Words with one consonant, like 'Emma' are easier than 'packet' with two consonant positions or 'snail' or 'school' with consonant clusters at the beginning.

Make a list of words your teenager can say clearly and see what similarities there are - in vowel and consonant type and position. Can he/she imitate two or three syllable words? Usually teenagers can say single syllable words much more accurately than two and three syllable words. Teenagers' progress will be affected by how difficult it is for them to make each single sound. If they can produce single sounds quite easily, then it will be more likely that they can move from one sound to the next swiftly enough to produce a word.

For focusing on the production of the rest of the word, after the initial sound, choose words where your teenager can say the initial sound, and that have a different ending, for example: coke/coat, bucket/buckle.

Although choosing sounds and words to practise seems and is quite difficult, we usually expect young people to learn how to say them just from listening to the words around them, without any structured help. Some selection of words that they are already trying to say, and defined practice activities, will make the task easier. Do not be too worried about 'doing it wrong'. Make sure the tasks are fun and designed to help your teenager to achieve the next step - if they can't, do more practice at an earlier step. Ideally, you will have a speech and language therapist who can help you. When practising two or three syllable words, encourage your teenager to tap out the number of syllables, in order to focus his/her attention on them.

For practising words, one way of deciding what is close to being achieved is to identify which words the young person can imitate but is unable to say clearly without a model to copy. The vocabulary checklists provide a column for you to record these words. Successful imitation indicates that the teenager can physically say the words and the sounds in the words, but has not yet said them enough to remember how to say them spontaneously. With some extra practice, they will learn to do so.

Important words, words that teenagers need, words that are likely to be practised every day

Another approach for choosing words to practise to improve teenagers' production is to choose words that they need or want to say, and practise these. One parent, who is also a speech and language therapist, describes how her 15-year-old son was successfully persuaded to improve his production of 'ch' when he had difficulty ordering chilli and chocolate chip cookies in a restaurant because his version sounded like ''silly'' and ''socolate sip''.^[56]

Teenagers will be keen to talk about favourite pop stars, pop music, TV programmes and 'soap' stars. They will be keen to order their favourite foods in the school canteen or in restaurants. They may be interested in purchasing magazines, sweets, snacks or other items in shops. They need to be able to say their name, address, birthday and age clearly. They need to be able to pronounce teachers' and learning support assistants' names, as well as the names of friends and leaders at clubs they attend. They may be keen to talk about sports and famous players.

Sound work can be combined with vocabulary and grammar work, by making books on topics of special interest to your teenager. With this approach parents will need to be very accepting of every effort, as some words will be very difficult for some teenagers, even though they are motivated so say them. You may need to break words down into smaller parts and practise these, and of course break sentences down into words to practise in turn (just as you do when reading word by word).

Targeted practice can help at any stage or age

Teenagers who talk fairly well will still benefit from these types of activities to improve their speech clarity, and some examples of more difficult words are included in the core checklists for this reason, for example 'ch' words and 'str' words.

Joining words together in sentences

Joining words together is more difficult than saying single words on their own, and it is typical for teenagers' clarity to fall back a little when they try to do this. But with practice they get better, although they should be able to say the single word clearly before they are expected to say it clearly in a sentence. You can build up two, three, four and five word sentences, practised with visual prompts, including symbols and printed sentences, to help teenagers to focus on their pronunciation. Remember to take turns and model the sentence for your teenager.

Dysfluencies

In teenage years, dysfluencies such as stuttering can become a cause for concern. They are common in teenagers with Down syndrome but usually improve or disappear over several years. ^[42] Researchers are not clear about the reasons for this ^[12] but the usual advice is to try to ignore these difficulties and not react to them. Some authors feel they are due to the anxiety which may result from the teenagers becoming more aware of their difficulties in saying what they want to say and being understood. The advice, therefore, is to be patient and to listen, maintaining eye-contact, interest and an encouraging smile. There is no evidence that doing speech work to improve intelligibility increases the likelihood of dysfluencies - provided, of course, that the speech work is not done in a manner that causes anxiety or stress. In fact, speech work done in the early years to increase clarity of production may help to prevent the development of stuttering.

Singing

Recently, the first author observed a significant improvement in the conversational speech intelligibility of a 32 year old woman with Down syndrome after she had taken singing lessons with a professional teacher for two years. Singing teachers know how to encourage clarity of production when singing and breath control. Many teenagers with Down syndrome enjoy singing, especially pop songs, so that the benefits of singing, especially when supervised by a singing teacher, should be explored.^[55]

Teaching vocabulary

All teenagers learn new vocabulary throughout their secondary school years as their knowledge increases. Vocabulary size is very important as it reflects the rate at which a young person is learning new information about his/her world and it enables (or restricts) the young person's ability to communicate. For teenagers with Down syndrome (and many other language delayed teenagers in regular classrooms) teaching vocabulary should be an explicit targeted activity. Vocabulary development is central to language development, and speech and language delays will have an adverse effect on progress in reading and writing, and on all other aspects of school learning and social communication opportunities.

A core vocabulary

The vocabulary covered on the three vocabulary checklists is a core vocabulary of over 800 words. It contains a range of nouns, verbs and adjectives that are used in everyday communication and, importantly, it contains the other parts of speech necessary to develop sentences and grammar. We therefore strongly recommend that you complete the vocabulary checklists in order to identify the gaps in your teenager's vocabulary, even if they have good speech and language skills. Some secondary age children will not have spoken vocabularies of over 800 words and the checklists will help you to identify the words that your teenager is not yet using in order to teach them.

Do not limit your vocabulary teaching to words from the checklists. Add any age-appropriate words for activities and events that your teenager is interested in, for project and subject work in class and for reading schemes, for example. In the secondary school years it is important to teach teenagers to link ideas and concepts together and to learn the vocabulary that links to places and events. This means that you might choose the vocabulary to work on a school project, or that you choose to work on the words in categories such as fruit, vegetables, birds, fish.

Choosing vocabulary to teach

These guidelines for choosing vocabulary are based on the principles used in vocabulary teaching studies reviewed in the overview module.

While vocabulary is being learned during everyday learning opportunities at home and at school, many teenagers with Down syndrome need more structured help to support their learning. The use of modelling (you name the object, picture, event or action) and imitation (you encourage your teenager to repeat the word with you) may still be necessary to help some teenagers.

Choose two sets of words, one set for comprehension activities from the words that your teenager does not yet understand and one set for production activities from words that your teenager understands but does not yet say.

First complete the appropriate vocabulary checklists to identify the words that your teenager understands and the words that he/she uses in speech or in sign and complete the speech sounds checklist. (Start with Vocabulary Checklist 1 even for a teenager, just to be sure that he/she does understand and use all these early words, and then Vocabulary Checklist 2). Choose to work with words that you feel your teenager will be interested in and that you can use naturally in lessons or daily activities - or by making a topic book.

These lists of target words will help you to make a planned effort to extend your teenager's vocabulary, but you will also be teaching them other new words during your daily talk with them at home and at school, so remember to update the checklist by reviewing it from time to time. If you keep your observation diary near to hand (see the 'Observation diary' section) you can note down words that your teenager is saying and understanding as you observe them.

Choosing vocabulary beyond the core vocabulary

The vocabulary covered by the checklists is only a core vocabulary provided for guidance. Even before they have all these words, many teenagers will be learning other words related to their experiences and interests, therefore choose any additional words to teach that are relevant to teenagers' daily lives.

In school, new vocabulary will be needed for literacy, numeracy and topic work and most of this can be anticipated in advance from curriculum guidance, and the school reading and number schemes. A 'word box' can be made to hold flashcards with the new vocabulary to be learned for reading or number or topic work that is planned. More than one word box may be useful, one for reading, one for maths and one for science or French for example.

For many lessons, it is possible to identify target vocabulary and make words in advance of the lesson, but for some subjects this may not be possible and the new words that come up in the lesson need to be noted and added to the teenager's word box. Picture or symbol materials may need to be devised to help teenagers to learn the meanings of new words.

Activities for vocabulary learning

All sorts of activities can support vocabulary learning, including finding, matching and sorting real objects, doing the same with picture or symbol cards and learning from picture books, picture dictionaries and computer programmes. These activities provide the opportunity to give teenagers many more opportunities of hearing a word and associating it with the correct meaning than will occur naturally during the course of the day.

The natural opportunities for drawing the teenager's attention to the language being used in every day interactions are equally important. Speak clearly to teenagers at all times, describing what they are doing or interested in and involving them in the conversation.

When teaching new topic vocabulary, remember to teach some relevant verbs, adjectives, pronouns and grammatical words as well as nouns so that the teenager can develop sentences and grammar. Remember that comprehension comes before production, especially for young people with Down syndrome.

It is very important to continue to expand the number of words that teenagers understand, even though they cannot say them, if we do not want to hold back cognitive development, that is, world knowledge, thinking and reasoning and remembering.

The teenager's understanding can be checked by asking them to choose the right picture or object from a choice of items for verbs and adjectives, place things correctly for prepositions and demonstrate the action for verbs. It is important to proceed at the teenager's pace and to be sure that he/she is really understanding and responding at each step. Plenty of fun repetition from playing games, singing rhymes and reading stories will help the learning process.

The importance of books

Reading books together is one of the most valuable activities that you can engage in with any teenager to assist their language learning. Books provide pictures to help you to teach new words and ideas but they also give practice at sentences. As you read even short stories, you are using grammatically correct sentences with expression and intonation. Favourite stories are read over and over, allowing your teenager to learn from the repetition (as they do from favourite games and pop songs).

Many people who study children's language learning emphasise that the main way in which children learn language is when it is embedded in familiar contexts, with all the familiar emotions and associations that go with them. We cannot over emphasise this point - it also applies to the language you use at bath times, mealtimes, when greeting and so on. The language is learned because it is experienced over and over in situations where the young person can see what you mean.

Stories and poetry in books provide another opportunity for learning in a situation of emotional warmth, closeness and sharing enjoyment of the story together. New information and the activities of characters outside daily experience can be shared from books.

Please find time to read with your teenager daily, at home and at school. If you can, join a library. Children's librarians are experts on the current books available for young people of different ages and stages. Here we are stressing the benefits of being read to and listening to language in the context of reading together. Later, we will discuss the benefits of teaching your teenager to read. An excellent guide to involving all students in the enjoyment of literacy, whatever their level of learning difficulty, is Literature for All by Nicola Grove.^[57]

Imitation with expansion

One of the best ways to help your teenager make the transition from the keyword combinations to grammatically correct sentences is to use imitation with expansion. To do this you imitate and expand what he/she has said, stressing the keywords.

For example, your teenager may say ''go school?'' while getting on his/her coat and you may respond with ''Are we going to school? Yes''. Or your teenager may point and say ''train'' and you say ''Yes, there's a train''. One more example might be, your teenager says ''more juice/toast'' and you expand to ''do you want more juice?'' or ''do you want more toast?''

Using visual and motor cues

Libby Kumin^[52] suggests the use of a pacing board to provide a visual and tactile reminder of the number of words your teenager is trying to use. For example, she suggests that a pacing board may consist of four or more coloured dots on a piece of cardboard, or four footballs put next to each other, or anything else that your teenager likes. As you say the words in a sentence, point to a spot on the board for each word in order. She suggests that helping your teenager to put their hands on the spots as they say the word will prompt them to recall the number of words that they need. Over time this will help them increase their combinations to two, three and four word or longer sentences. 

Encouraging your teenager to continue to sign as he/she speaks may also act as a prompt as they join words. It seems that if they sign each word they may well be able to recall the signs in sequence, and this will act as a prompt for the words that they need. However, remember that at this stage we do not want signs to be used without an explicit reason for them, so you might use signs to model a two or three word utterance but not use the same signs in other contexts where the teenager can understand and use the words without help. It will also be apparent that the use of printed words can also help the teenager to produce multi-word sentences.

Teaching reading

The teaching of reading and the use of print to support practice should begin in the primary years for children with Down syndrome, therefore many children will enter secondary school with functional reading skills, able to write sentences and short texts with minimal help. Some will have a 'sight vocabulary' (printed words that she/he can read) and some will have not yet started to read. If a teenager has not yet started to read, we would introduce reading by making simple books on topics the teenager is interested in, and read them together, as described in Reading and writing development for children with Down syndrome (11-16 years).^[DSii-07-05]

Researchers worldwide agree that children and teenagers with Down syndrome are visual learners and benefit from reading instruction.^{[23-25,14,40]} Their visual discrimination and visual memory skills are strengths, while their auditory discrimination and auditory memory skill are a weakness. The approaches used in the Australian Latch-on programme^[23] and in the use of computers by Meyers^[26,44] - both outlined earlier in the section on 'Literacy activities and using computers' - will be appropriate for a wide range of teenagers.

We have been teaching children and teenagers with Down syndrome to read for the past twenty years. Progress will vary but many young people make surprisingly fast progress and the words that they see and read in print soon emerge in their spontaneous spoken language. We would speculate that we are using print as a way into spoken language for these children. Please look at the programme described in the reading module and make maximum use of reading to help your teenager.

All speech and language targets can be linked to literacy work. Phonics activities will help speech sound awareness and sound production skills. Literacy work at word, sentence and text level will link to vocabulary, grammar, narrative and conversation targets. Supported reading will help sentence planning and fluent production of sentences.

One ten year old known to the authors made the link between her phonics knowledge and her speech intelligibility for herself. After several attempts to get her mother to understand a word that she was saying, she 'sounded' the word out, identifying the letters in the word she was trying to say, so that her mother could understand her!

Symbols

Picture symbol systems are often advocated for use with young people with learning delays and young people with Down syndrome. These are often associated with sign systems such as Makaton signs, but we do not recommend that they are used unless your teenager is having particular difficulty with learning to talk or to read. We always use ordinary printed words to teach children to read, from as early as two years of age. If properly taught, almost all children will learn the words as easily as symbols. In school situations, placing the word cards around the environment - with picture clues if necessary - will be far more likely to teach teenagers to read than putting symbols everywhere. Like spoken words, the more often a printed word is seen in a context where you can see what it means the faster a teenager will learn and remember it.

If symbols are used in an unplanned way, learning symbols and then print is like learning two languages, like learning Chinese and then learning English. A further problem with the use of sign and symbol systems is that they cannot teach English grammar, unless adapted to do so. Written English is essentially the same as spoken English.

Symbols can however be used to support reading and writing of print if used in a planned way. For example, symbols can help to prompt the grammatical words or new words in sentences. Symbols can also be used to interest teenagers in reading and writing, when they have already experienced failure and are not keen to try reading activities. A symbol-supported system, particularly used on the computer, may motivate teenagers because it looks like something new, especially if they are finding reading difficult. Writing with Symbols 2000 is a programme that will help many pupils.

Teaching grammar

Two and three words together

Many teenagers with Down syndrome will be talking in short sentences when they start at secondary school but some will be using two and three keywords together. Examples of the range of two and three word phrases that young people may use is set out in the Sentences and grammar checklists and record sheets.

All the evidence indicates that few children with Down syndrome will learn grammar from simply listening to everyday conversations, although this is how other children learn grammar. The main reason for this may be the slow development of the verbal short-term memory span. Learning grammar involves the processing of sentences rather than single words and this will be very difficult for most children with Down syndrome. There are many ways in which various aspects of grammar can be taught using games but we would argue that reading is the most powerful way to teach sentences and grammar once children have reached a two-word stage in comprehension.

Your teenager is learning grammar all the time you are talking to them in natural sentences.

One simple rule mentioned earlier, imitation with expansion, will be effective to help your teenager progress from two and three words together to proper sentences:-

• Listen to your teenager's key words and expand them into the shortest complete sentence. For example ''Jenny gone'' to ''Jenny has gone'' or ''Jenny has gone to the shops'', ''Cat sleeping'' to ''The cat is sleeping''. ''Play Gameboy'' to ''Can I play with the Gameboy, please?'' ''Mum go car'' to ''Mum has gone out in the car'', ''Dad go work'' to ''Dad is going to work''. You will already be using these expansions naturally (without thinking) as you talk to your teenager during the day at home or at school. This simple approach will also ensure that you teach using examples that are relevant to your teenager and that will be able to be used by him/her often when he/she wants to communicate.

You can use the same strategy when thinking about making language books. Words that you wish to teach from the vocabulary lists, such as prepositions and joining words will also give you ideas for sentences to practise in games or with reading activities. For example ''Put the drink on the table'', ''The video is here, not over there'', ''There is a burger and a coke'', ''If you get your coat, we can go to the disco'', ''We need our coats because it is raining''.

You can make use of an observation diary to help you observe and encourage your teenager's grammatical development and ability to use longer sentences. Keep your diary near to hand and note down the phrases and sentences that your teenager is using, both in imitation and spontaneously. This will help you to be aware of exactly how he/she is putting words together and it will help you to follow the guidance on expansion above.

Conversation diaries

The first author developed the use of conversation diaries during the research project set up to evaluate the effectiveness of language intervention for teenagers with Down syndrome (described in the 'Teaching grammar' section), and they were popular with the teenagers, their parents and teachers. They can be used to support young people of any age to develop their use of sentences and grammar.

A conversation diary is a personal book, which your teenager can take between home and school.

In the book, write a sentence about something that your teenager has done or is going to do, that he or she would like to tell his/her friends/teacher about - using the words that he or she would use to tell someone about this event. For example, ''Last night, I watched TV'', ''I am going on holiday tomorrow to Spain'', ''We made a cake at Grandma's'', ''I helped Mrs Smith to tidy the table today'', ''Mum and I will go to the park tomorrow/on Saturday/after school'', ''Mrs Andrews helped me on the computer today. We made a book about electricity'', ''I played the drum in music today'', ''Ben and I played football in the playground''.

The conversation diary will help your teenager to say complete sentences and to be able to share their experiences with family and friends. If he/she can read, they will be able to write (perhaps with help) their own sentences and read them. If he/she is not yet able to read and write, then you should read the sentence and help your teenager to imitate it).

The conversation diary will serve two useful purposes. It will support your teenager's development of spoken language, sentences and grammar, and it will enable him/her to tell everyone what they do at home and at school. When a young person has limited communication skills, they are not able to tell Mum and Dad what they did at school today and they are not able to tell their teacher or friends about the important experiences that they have out of school. The conversation diary can bridge that gap and enable everyone to talk with them about their daily lives. It is important that the young person is actively engaged in choosing what he/she wants to tell using the conversation diary. It is one of the times when you will use expansion to decide on what to write. Ask the young person what he/she/wants to tell and make the shortest correct sentence from their keywords. For example, if the young person says ''Played drum'' you write ''I played the drum today''.

Syntax and grammar

While we know that most teenagers with Down syndrome have difficulty mastering all the grammar and using it in their speech, there have been almost no intervention studies to provide guidance on the best ways to help them. We know that both speech production difficulties and auditory short-term memory difficulties play a part, so speech work will help and so will reading activities. We encourage the use of an observation diary in which you simply note down how your teenager does try to express themselves in order to see how to help them to progress, using expansions as described above, in speaking to them and in writing activities.

Grammar will also be taught in all the reading and project activities that you are engaged in across the curriculum.

Grammar can be discussed under two headings - syntax and grammar.

Syntax refers to understanding the way word order changes meaning, for example, ''Pat hits Mary'' does not mean the same as ''Mary hit Pat''. Similarly ''Dad has gone to work'' changes from a statement to a question if we change the word order to ''Has Dad gone to work?''

Grammar refers to the 'bound morphemes', the word endings that change meaning (for example, 'ed', 'ing' or 's ') and the 'function' or joining words such as 'a', 'the', 'is', 'are', 'if'. The function words seem to be the most difficult for teenagers with Down syndrome, and this is also true for other children and teenagers with speech and language impairments.

Syntax

Teenagers will begin to understand and use word order rules in their 3 and 4 keyword sentences and they then move on to question forms and more complex sentences.

Question forms

Your teenager will have displayed understanding of question such as ''What's that?'', ''Who is coming?'' from quite early, and they will ask questions at the one and two word stage by pointing, but use of question forms in spoken language will come later. Remember to use them as you talk to your young person - and to use 'can' and 'will' - ''Can you come here please?'', ''Could you go and look for your shoes, please?'', ''Will you take this to Dad please?'', ''Will you drink up your juice please?''

It is possible to model questions and answers to encourage your young person, for example, ''Why are we putting our coats on? - Because it is raining'' or ''When are we going out? - When Gran comes''. In your observation diary, keep a note of the way in which your teenager 'asks' questions and her/his use of question words. You will also be marking them on the vocabulary lists.

Negatives

As all parents soon find out, from quite early on children understand and use 'no' when they do not want something or they do not want to do something!

Picture materials can also be used to teach negatives, for example ''He has his glasses on'', ''He has no glasses on'', or ''He hasn't got his glasses on''. Games to encourage your teenager to use negatives can be played - ''Have you got a hair band on?'' - and the answer modelled ''No, Jenny hasn't got a hair band on?'' This game can be played in front of a mirror. In your observation diary, keep a note of the way in which your young person indicates negatives and his/her use of 'negative' words. You will also be marking them on the vocabulary lists.

Grammar

When a child or teenager has some 250 to 300 words in her/his vocabulary, he/she will begin to use some of the grammatical markers (for example for plurals or tenses) and more of the function words in their sentences, until they talk in grammatically complete sentences. When you begin to work with Vocabulary Checklist 3, you will use these markers on the words used in sentences.

Plurals

The use of/s/on the end of a word to indicate a plural is a grammatical rule that is learned early in typical development and simple games can be played to show one or more than one item and use the plural/s/form. Teenagers with Down syndrome may understand the plural/s/but not be able to put the/s/on the words they say because of speech sound production difficulties. There are a number of plural words that are irregular such as feet, and teeth. These just have to be learned and some of the most common ones are in the vocabulary checklists. In your observation diary, keep a note of the way in which your teenager indicates 'more than one' and the words that he/she is using. You may be marking some of them on the vocabulary lists. When he/she uses the/s/on words, record this on the Sentences and Grammar checklist.

The use of plurals in sentences also requires the use of the correct auxiliary with the verb, for example, ''the boy is running'', ''the boys are running''.

Possession

The use of/s/on the end of a word to indicate possession is also learned early. Here again, teenagers with Down syndrome may clearly demonstrate comprehension of the possessive form but not be able to actually sound the/s/on a word when speaking. They may use possessive pronouns such as 'mine' before using/s/on words. In your observation diary, keep a note of the way in which your teenager indicates 'possession' and the words that he/she is using. You will also be marking some of them on the vocabulary lists. When he/she uses the/s/on words, record this on the Sentences and Grammar checklist.

Function words

Prepositions

Some of the first grammatical words children master are prepositions, such as 'on', 'in', 'under'. Games to teach the meanings of these are not difficult to plan. More difficult pronouns, such as beside, above, below, may not be understood by young people of secondary school age. These can be used in sentences and acted out by teenagers in games. In your observation diary, keep a note of the way in which your teenager indicates 'place' and the prepositions that he/she is using. You will also be marking them on the vocabulary lists.

Pronouns

Pronouns are a little tricky to demonstrate, especially 'I', 'you', and 'me'. Games played in front of a mirror can help, pointing to yourself while modelling 'I' and helping your teenager to do the same. Children usually refer to themselves using their own name or 'me' before using 'I'. The use of 'carrier' phrases, such as 'I like....'. or 'I see ...' , and their use in home-made books with photos of your young person can help.

In your observation diary, keep a note of the way in which your teenager indicates 'person' and the pronouns that he/she is using. You will also be marking them on the vocabulary lists.

Articles

The use of the articles 'the' and 'a', and others such as 'some', takes a while to develop. These words, and the auxiliary verbs such as 'is' and 'are', may be difficult because they add little to the meaning of the sentence. They are also not stressed in normal talk and therefore may be difficult to hear and to process in the flow of words. In our experience, young people with Down syndrome do not easily learn to use them in their language and reading them in sentences will help them.

In your observation diary, keep a note of the way in which your teenager is talking and note down any use of articles. You will also be marking them on the vocabulary lists. When you have heard the use of 'a' and 'the' consistently, tick and date the checklist.

Tenses

There are many tenses in the English language, but we have simplified them to present, future and past tenses. To use many tenses properly, an auxiliary or 'helping' verb is used, for example, ''He is going'', ''They will be going'', ''He has been'', ''They are running''. It takes most children with Down syndrome a number of years to master the use of auxiliaries and some individuals never learn to use them. However, most teenagers do learn to use present, present progressive and simple past and future tenses to convey these meanings appropriately.

Children use the present tense of verbs first for example 'push', 'jump', 'sleep', 'run', and this is the way most of the verbs appear in the vocabulary checklists.

Present progressive tense

The next tense children learn is the present progressive 'ing' form, for example, pushing, jumping, sleeping, running. To use this form correctly in sentences they need to use auxiliary verbs -for example, ''I am pushing'', ''he is jumping'', ''they are sleeping'', ''we are running''. You will note that the auxiliaries change with the pronouns (I am, he is, she is, Mummy is) and with singular or plural agents (He is, they are). However children will use the 'ing' form of the verb on its own before they begin to use the auxiliaries. When you hear your teenager using 'ing' on verbs, tick and date the checklist.

Past tenses

The past tense of verbs comes in two forms, regular and irregular. The regular form is the 'ed' form, for example, jumped and pushed. The irregular forms are all different and have to be learned individually, for example, slept and ran.

Children learn a number of irregular past tense forms before they use the 'ed' form. Early ones may include 'broke', 'came', 'cut', 'drank', 'fell', 'gave', 'had', 'made', 'ran', 'sat', 'saw', 'took', 'were', 'went'. A further list of irregular past tense verbs is included in the Sentences and Grammar checklist.

Use of the 'ed' ending

In typically developing children, there is a stage when they seem to realise that 'ed' on the end of a word creates a past tense and they 'over use' it - saying 'buyed', or 'goed', for example. In our experience, young people with Down syndrome rarely do this but we would be interested to know if you hear your teenager doing this.

In your observation diary, keep a note of the way in which your teenager indicates past events and her/his use of the 'ed' ending. In order to use the past tense and to help your child understand, a wall chart for the week or the month can be a great help. Mark significant events on the chart, then you can look at it with your teenager and say, ''Yesterday, we went to the park'', or ''Last week, we rowed a boat on the pond at the park''.

There are other past tense constructions such as 'we have been, he has jumped, he might have jumped before'. We suggest that you leave these to develop through reading and writing activities. If at the stage your teenager is learning to read, you help her/him to keep a simple 'conversation' diary, you will find that you begin to use these constructions.

Young people with Down syndrome will understand the language more quickly if the examples used refer to their own activities and actions, rather than to characters in a book - hence the value of keeping a diary.

In your observation diary, keep a note of the way in which your teenager talks about past events and think of ways to expand her/his own combinations to fully grammatical sentences for practice.

Future tenses

The future tense comes next, but again needs the use of auxiliaries and the verb 'go', for example, ''We are going to Gran's house'', ''Dad is going to work on Monday'', ''You are going to school tomorrow'', ''He will be going to school tomorrow''.

The wall planner for the week or the month will help you to use future tenses and to encourage your teenager to do so. Mark the future events in the next week and talk to your teenager about them. You can extend the planner to cover the year - and teach days of the week, seasons, months, weather - time words, 'tomorrow', 'today' - and time concepts - 'next week', 'last month', 'before', 'after'- all with reference to events on the wall planner that your teenager takes part in.

In your observation diary, keep a note of the way in which your teenager talks about future events and think of ways to expand her/his own sentences to fully grammatical ones for practice.

More advanced structures

There is a lack of research into the emergence of more complex structures in the language of teenagers with Down syndrome and even less research on effective ways to teach them. However, the evidence does suggest that both modelling by expanding your teenager's utterance to the correct sentence and getting your teenager to imitate by copying you or by reading, are both important strategies. Most teenagers with Down syndrome will be using 3 and 4 word sentences by 11 years of age, some will be further ahead than this and some more delayed. Therefore, most teenagers will not use complex sentences until they are in secondary school or even later. Young adults with Down syndrome often continue to improve their spoken language through their twenties and beyond.

The examples included here are those that will be useful in secondary school, such as comparatives for understanding quantity. More research is needed on the development of grammar in the spoken language of individuals with Down syndrome and we suggest that you continue to use your observation diary to note down the sentences your teenager is using as a basis for deciding how to extend them.

Comparatives

Once children have some understanding of words such as big and small, they move on to understanding that size can be relative, for example, that John can be taller than Bill but shorter than Tom.

Common examples of comparatives are:-

• Big, bigger, biggest
• Small, smaller, smallest
• Dad is taller than Mum
• Jenny is taller than Bob but Mum is taller than Jenny

In this example - Dad is the tallest and Bob is the smallest. Many young people with Down syndrome will be in secondary school before they really understand comparatives. We have used the example of height because it is easy to choose real life examples from family or school friends to teach it. For example, find a friend who is taller and a friend who is shorter than your teenager. Take photographs of him/her with each friend and paste them in a book, with the appropriate sentence written underneath. (John is taller than Bill. John is shorter than Tom.) Take a photograph of all three friends and write the sentences ''Tom is the tallest'', ''Bill is the shortest''.

More complex sentences

There are many more complex sentence constructions such as embedded clauses, passives and the use of 'but not' for example. You may not feel that your teenager needs to be able to use these but they are included to provide further development for teenagers who are making good progress and are reading and writing at an 8 year level or above. Many complex sentence forms will be used in reading books at this level and teenagers' ability to understand what they read will be undermined if their grammatical knowledge is too limited.

Embedded clauses

''The bull chasing the man is black'' and ''The boy who is hungry is getting his dinner'' are examples of sentences containing embedded clauses.

A teenager who can understand, ''The bull is chasing the man'' and ''The bull is black'' as two separate sentences, may not understand the compound sentence. For teenagers with Down syndrome, reading these sentences linked with appropriate pictures and explanation will help. Their limited verbal short-term memory skills may make sentences of this length and complexity very difficult to listen to and process.

Passive sentences

''Sally is being teased by her brother'', ''The man is being chased by the bull'' are examples of passive sentences.

''The man is being chased by the bull'' is the passive form of ''the bull is chasing the man''. Many typically developing children do not master passives until they are in school and reading from books. If you wish to teach this construction to teenagers, again use their everyday experiences to make teaching materials. They can act out - for example, ''Jenny is brushing Annie's hair'' to learn that the passive form ''Annie's hair is being brushed by Jenny'' has the same meaning as the active form - and then write the two examples down under a picture of the action. ''Billy is cleaning the car'' or ''the car is being cleaned by Billy''.

X but not Y sentences

''It is windy but not raining''. ''Billy has fallen off his bike but he is not hurt''. This type of sentence can be taught with actions and simple picture materials.

These are just some examples of complex sentences that we all use. However, we would remind you that if you listen to what your teenager wants to talk about and then expand their utterances into correct sentences, you will teach them all the useful grammar that they need and that they will be able to use in real situations. Always try to teach using examples that are age-appropriate and relevant to your teenager's interests, and will be able to be used by them often when they want to communicate in real situations.

Computers and communication aids

Computers and communication aids can make a significant contribution to the speech and language progress and communicative effectiveness of teenagers with Down syndrome. In the USA this topic is referred to as assistive technology, and a useful chapter on the use of assistive technology by Jamie Murray-Branch and Julie Gamradt ^[39] is included in the excellent practical book Improving the Communication of People with Down Syndrome.^[14] They identify that assistive technology can help individuals to:

1. Enhance thinking skills related to communication development
2. Learn to use symbols (i.e. words) for communication
3. Use alternate methods to express ideas when speech is difficult
4. Learn to use words in combination to create longer sentences
5. Learn to understand sentences of greater length
6. Establish social relationships with peers.

A range of software suitable for use by most teenagers is available, including programmes produced by Laureate Learning to support vocabulary learning and sentence structures; programmes such as Clicker 4, Book Spinner, Inclusive Writer, which support language and literacy work, and Writing with Symbols 2000, which includes symbols to support. (Suppliers for these software programmes are listed in the Resources section.)

There is also a range of communication 'low-tech' aids, such as communication boards, which can be developed to support the teenagers with more limited language and with severe speech intelligibility problems. Some may also benefit from aids which 'speak' for them - but the advice of a speech and language therapist should be sought before purchasing a communication aid of this sort, as he/she can make a proper assessment of an individual's needs, and will be familiar with currently available aids.

A practical chapter on how to make use of assistive technology, i.e. develop simple communication aids, will be found in Libby Kumin's recently published book Classroom Language Skills for Children with Down Syndrome. ^[38] This book focuses mainly on how to assist young people to cope with the language of the classroom, particularly the mainstream classroom. It is not a book on speech and language therapy. However, it is full of practical ideas and illustrations for worksheets and activities that could be used to implement many of the activities recommended in this module.

Overview

This module has been written to encourage you, as a parent or teacher, to make a carefully planned effort to accelerate your teenager's speech, language and communication skills. We hope that you have found the checklists, the advice and activities useful and relatively easy to use. We realise that we have provided a large amount of information and have asked you to spend some weeks learning about communication and assessing your teenager in order to make use of the programme.

We have included this amount of information and detailed guidance because we think that it is impossible to exaggerate the importance of speech and language development for every aspect of your teenager's social and cognitive development. Please let us know how helpful or difficult you have found this module and please contact us if you need further help.

If your teenager is in a mainstream school or a special school, try to integrate targets for vocabulary, grammar and speech work into the regular curriculum. Try to ensure that your teenager has a language book and a conversation diary. Remember to identify new words that will be needed for topic work and add them to vocabulary lists for practice. Learning to say a new word such as centimetre or volcano correctly can be assessed as an achievement in a maths or geography lesson.

Remember that you are helping your teenager to progress all day every day, at home and at school, as you talk naturally to them - the extra activities will help but are an addition to all the language learning that is occurring naturally. Remember to speak clearly and to encourage eye-contact with your teenager in these everyday conversations. They need to be looking and listening. They will also be helped by visual cues in sign or picture. Remember also that background noise will make listening much more difficult for them if they have any hearing loss. Small rooms help, turn off the TV and radio at home and sit teenagers near the front of the class in school.

Teenagers with Down syndrome will also benefit from as much social experience at clubs and activities as possible. This will increase their range of experience and communication opportunities.

Speech and language therapy

It is clear from the evidence reviewed in this publication and in Speech and language development for individuals with Down syndrome - An overview that teenagers with Down syndrome will benefit from speech and language therapy during their secondary school years. In many countries, this will not be a possibility, and parents and teachers will need to use these materials without expert help. Parents in this situation might find working together in a small group helpful.

Goals for speech and language therapists working with 11-16 year olds with Down syndrome

• to have up-to-date knowledge of the specific research literature on speech and language development, working memory and effective therapies for teenagers with Down syndrome
• to understand the significance of the specific impairment in the phonological loop component of working memory for the speech and language profile associated with Down syndrome
• to understand the importance of reading work to support the development of vocabulary, grammar and speech clarity, using strengths in visual memory
• to understand the importance of auditory discrimination for speech sounds, phonics activities, phonological awareness training and speech work for improving working memory function
• to have clear targets for 4 areas of work; speech, vocabulary, grammar and communication skills, and to keep detailed records of progress
• for vocabulary and grammar to have separate targets for comprehension and for production, as comprehension is typically significantly ahead of production for both vocabulary and grammar
• for speech work, separate targets may be needed for articulation, phonology and intelligibility (pacing, voice etc.)
• to review oral-motor function, feeding, chewing and drinking patterns and advise accordingly
• all targets should be shared with parents, teachers and assistants
• teenagers with Down syndrome should be seen at least monthly in school, targets reviewed and activities set for parents, teachers and assistants to include in their daily routines
• these activities should be modelled with the teenager by the speech and language therapist, if parents and assistants are expected to deliver therapy
• ideally, all teenagers with Down syndrome of secondary school age should have weekly individual or group sessions of speech and language therapy with a therapist who has specialist knowledge and the skills to address their profile of difficulties, particularly for speech and intelligibility work.

Reviews of the literature supporting these recommended goals ^[12,13] and specialised workshops ^[14] are available for speech and language therapists. Specialised accredited postgraduate training is being developed at the University of Portsmouth for speech and language therapists and for teachers to begin in autumn 2002.

The way in which services are offered obviously depends on the availability of speech and language therapists. It is important that therapists have some specialist training and knowledge of the specific needs of children and teenagers with Down syndrome, and access to the research literature and appropriate resources. Experience of working with other young people with moderate to severe learning difficulties is not an adequate basis for working with teenagers with Down syndrome.

A typical level of service to teenagers included in mainstream schools in the UK will be a visit to school by a speech and language therapist two to four times each term, to assess the young person's progress and set targets for activities. The aim of this expert therapy should be to assist the parents and teachers or classroom assistants to become experts themselves, by setting appropriate targets with them for speech, language and communication work, and then modelling effective activities and interactions for them, to enable them to help their teenager all day, every day, during ordinary daily routines and through planned activities and teaching.

We have found that classroom assistants and parents appreciate being shown how to do the activities by watching the speech and language therapists work with their teenager, rather than just having the activities explained. It is also helpful if the speech and language therapist can help to set appropriate targets for reading, writing and spelling work based on the teenager's language comprehension level and expressive speech needs. It is especially helpful if the therapist is able to build the teenager's speech work and language work into the daily curriculum of the classroom.

In some areas, group sessions are offered to young people with Down syndrome who meet up with teenagers from other schools for speech and language therapy. These groups may also have other goals such as helping to develop age-appropriate behaviour and to provide the social opportunity to mix with other teenagers with Down syndrome, to interact with others at a similar developmental level and develop social skills, and to explore over time their understanding of having Down syndrome.

At the present time, there is no ideal model of service that is universally agreed upon and, of course, each young person with Down syndrome should receive a service based on specific individual needs, not on the diagnosis. As inclusion develops it is likely that speech and language therapy services will move to being school based, making the level of service available to each teenager much more frequent and appropriate. This will lead to the speech and language therapist being a full member of the school team and to make a much more significant contribution to the curriculum and the speech, language and communication environment in school.

Acknowledgements

The authors would like to thank all of the children, families and colleagues that they have had the privilege to work with and learn from over a period of more than 20 years.

The authors would also like to thank Professor Ben Sacks for his helpful comments on various drafts of this module. However, the responsibility for the final content, and any errors, is solely that of the authors.

Terminology

The term 'learning difficulty' is used throughout this module as it is the term currently in common use in the United Kingdom. The terms 'mental retardation', 'intellectual impairment', and 'developmental disability' are equivalent terms, used in other parts of the world.

The term 'teenagers' has been used as the generic term for this age group, even though the youngest are 11 year olds, as the authors consider that the term 'children' is no longer appropriate.

In this module, the authors have adopted a straightforward and direct style in the practical section, in which the reader is addressed in the first person. They have done this because the module is mainly concerned with practical activities and instructions, and the authors have found that this direct, active style has been appreciated by readers in previous publications.

References

1. Buckley, S.J., Bird, G., Sacks, B., and Archer, T. (in press). The development of teenagers with Down syndrome in 1987 and 1999: implications for families and schools. Down Syndrome News and Update, 2(2). [Open Access Full Text ]
2. Buckley, S.J., Bird, G., Sacks, B., and Archer, T. (in press). A comparison of mainstream and special school education for teenagers with Down syndrome: effects on social and academic development. Down Syndrome Research and Practice, 9(3). [Open Access Full Text ]
3. Buckley, S. J. (1993). Developing the speech and language skills of teenagers with Down syndrome. Down Syndrome Research and Practice, 1(2), 63-71. [Open Access Full Text ]
4. Buckley, S. J. (1995). Improving the expressive language skills of teenagers with Down syndrome. Down Syndrome Research and Practice, 3(3), 110-115. [Open Access Full Text ]
5. Chapman, R. S. (1997). Language development. In Pueschel, S. M. and Sustrova, M. (Eds.), Adolescents with Down syndrome: Toward a more fulfilling life. (pp. 99-110). Baltimore, MA, USA: Paul H. Brookes Publishing Co.
6. Chapman, R.S., Schwartz, S.E., & Kay-Raining Bird, E. (1991). Language skills of children and adolescents with Down syndrome: I. Comprehension. Journal of Speech and Hearing Research, 34, 1106-1120.
7. Chapman, R.S., Seung, H-K., Schwartz, S.E., & Kay-Raining Bird, E. (1998). Language skills of children and adolescents with Down syndrome: II. Production deficits. Journal of Speech, Language, and Hearing Research, 41, 861‑873.
8. Chapman, R. S. (1999). Language development in children and adolescents with Down syndrome. In Miller, J. F., Leddy, M., and Leavitt, L. A. (Eds.), Improving the Communication of People with Down Syndrome. 3. (pp. 41-60). Baltimore, MD: Paul H. Brookes Publishing Co.
9. Gunn, P. and Crombie, M. (1996). Language and speech. In B. Stratford and P. Gunn (Eds.), New approaches to Down syndrome. London: Cassell.
10. Fowler, A. E. (1995). Linguistic variability in persons with Down syndrome: Research and implications. In Nadel, L. and Rosenthal, D. (Eds.), Down syndrome: Living and learning in the community. (pp. 121-131). New York, NY, USA: Wiley-Liss.
11. Rondal, J. A. (1996). Oral language in Down syndrome. In Rondal, J. A., Perera, J., Nadel, L. and Comblain, A (Eds.), Down Syndrome: Psychological, psychobiological and socio-educational perspectives. London, England UK: Whurr Publishers, Ltd.
12. Miller, J. F., and Leddy, M. (1999). Verbal fluency, speech intelligibility, and communicative effectiveness. In Miller, J. F., Leddy, M., and Leavitt, L. A. (Eds.), Improving the Communication of People with Down Syndrome. 5. (pp. 81-91). Baltimore, MD: Paul H. Brookes Publishing Co.
13. Dodd, B. and Thomson, L. (2001). Speech disorder in children with Down's syndrome. Journal of Intellectual Disability Research, 45 (4), 308-316.
14. Miller, J.F., Leddy, M. and Leavitt, L.A. (1999). Improving the communication of people with Down syndrome. Baltimore: Paul Brookes Publishing, MA, USA.
15. Chapman, R.S. and Hesketh, L.J. (2001). Language, cognition and short-term memory in individuals with Down syndrome. Down Syndrome Research and Practice, 7 (1), 1-7. [Open Access Full Text ]
16. Gathercole, S., and Baddeley, A. (1993). Working memory and language. Hove, UK: Lawrence Erlbaum Associates.
17. Rondal, J. A. (1995). Perspectives on grammatical development in Down syndrome. In Nadel, L. and Rosenthal, D. (Eds.), Down syndrome: Living and learning in the community. (pp. 132-136). New York, NY, USA: Wiley-Liss.
18. Fowler, A.E., Gelman, R., & Gleitman, L.R. (1994). The course of language learning in children with Down syndrome. In H. Tager-Flusberg (Ed.), Constraints on Language Acquisition (pp. 91-140). Mahwah, NJ: Lawrence Erlbaum Associates.
19. Horstmeier, D. (1988). ''But I don't understand you'' - The communication interaction of youths and adults with Down syndrome. In S.M. Pueschel (Ed.), The young person with Down syndrome: Transition from Adolescence to Adulthood. Baltimore: Paul Brookes Publishing.
20. Jenkins, C. (2001). Adults with Down syndrome: An investigation of the effect of reading on language skills. Unpublished PhD Thesis. University of Portsmouth, Portsmouth, UK.
21. Cholmain, C. N. (1994). Working on phonology with young children with Down syndrome: a pilot study. Journal of Clinical Speech and Language Studies, 1, 14-35.
22. Dodd, B., McCormack, P., and Woodyatt, G. (1994). Evaluation of an intervention program: relation between children's phonology and parents' communicative behavior. American Journal of Mental Retardation, 98(5), 632-645.
23. Van Kraayenoord, C.E., Mari, K.B., Jobling, A. and Ziebarth, K. (2001). Broadening approaches to literacy education for young adults with Down syndrome. In M. Cuskelly, A. Jobling & S. Buckley (Eds.), Down Syndrome Across the Life Span. London, UK: Whurr.
24. Farrell, M. and Elkins, J. (1991). Literacy and the adolescent with Down syndrome. In C.J. Denholm & J. Ward (Eds.), Adolescents with Down syndrome: International perspectives on research and programme development. Victoria: University of Victoria.
25. Farrell, M. (1996). Continuing literacy development. In B. Stratford and P. Gunn (Eds.), New approaches to Down syndrome. London: Cassell.
26. Meyers, L.F. (1998). Using computers to teach children with Down syndrome spoken and written language skills. In L. Nadel (Ed.) The Psychobiology of Down Syndrome. New York: National Down Syndrome Society, pp. 247-265.
27. Laws, G. Byrne, A. and Buckley, S.J. (2000). Language and memory development in children with Down syndrome at mainstream schools and special schools: a comparison. Educational Psychology, 20 (4), 447-457.
28. McGuire, D.E. and Chicoine, B.A. (1999). Life issues of adolescents and adults with Down syndrome. In T.J. Hassold and D. Patterson (Eds.) Down Syndrome: A Promising Future Together (pp. 205-219). New York, NY, USA: Wiley-Liss. See also website at: www.advocatehealth.co./sites/hospitals/luth/adsc
29. Kernan, K.T. and Sabsay, S. (1996). Linguistic and cognitive ability of adults with Down syndrome and mental retardation of unknown etiology. Journal of Communication Disorders, 29, 401-422.
30. Stoel-Gammon, C. (2001). Down syndrome phonology: Developmental patterns and intervention strategies. Down Syndrome Research and Practice, 7 (3), 93-100. [Open Access Full Text ]
31. Hamilton, C. (1993). Investigation of the articulatory patterns of young adults with Down's syndrome using electropalatography. Down Syndrome Research and Practice,, 1 (1), 15-28. [Open Access Full Text ]
32. Pryce, M. (1994). The voice of people with Down's syndrome: An EMG biofeedback study. Down Syndrome Research and Practice, 2 (3), 106-111. [Open Access Full Text ]
33. Leddy, M. and Gill, G. (1999). Enhancing the speech and language skills of adults with Down syndrome. In J.F. Miller, M. Leddy and L.A. Leavitt, (Eds.), Improving the Communication of People with Down Syndrome. Baltimore: Paul Brookes Publishing.
34. Quail, S. (2000). The social inclusion of pupils with Down syndrome in mainstream secondary schools. Unpublished BSc dissertation, University of Portsmouth.
35. Kumin, L., Goodman, M., and Councill, C. (1996). Comprehensive speech and language intervention for school-aged children with Down syndrome. Down Syndrome Quarterly, 1(1), 1-8.
36. Rosin, P. and Swift, E. (1999). Communication interventions: Improving the speech intelligibility of children with Down syndrome. In J.F. Miller, M. Leddy and L.A. Leavitt, (Eds.), Improving the Communication of People with Down Syndrome. Baltimore: Paul Brookes Publishing.
37. Van Borsel, J. (1988). An analysis of the speech of five Down's syndrome adolescents. Journal of Communication Disorders, 21, 409-421.
38. Kumin, L. (2001). Classroom language skills for children with Down syndrome: A guide for parents and teachers. Bethesda: Woodbine House, MD, USA.
39. Murray-Branch, J.E. and Gamradt, J.E. (1999). Assistive technology: Strategies and tools for enhancing the communication skills of adults with Down syndrome. In J.F. Miller, M. Leddy and L.A. Leavitt, (Eds.), Improving the Communication of People with Down Syndrome. Baltimore: Paul Brookes Publishing.
40. Fowler, A. E. (1999). The challenge of linguistic mastery in Down syndrome. In T. J. Hassold, and D. Patterson, (Eds.), Down Syndrome: A Promising Future, Together. (pp. 165-182). New York, NY, USA: Wiley Liss.
41. Dodd, B., and Leahy, J. (1989). Phonological disorders and mental handicap. In M. Beveridge, G. Conti-Ramsden and I. Leudar, (Eds.), Language and communication in mentally handicapped people. London, UK: Chapman and Hall.
42. Pueschel, S.M. and Hopman, M.R. (1993). Speech and language abilities of children with Down syndrome: A parent's perspective. In A.P. Kaiser and D.B. Gray, (Eds.), Enhancing Children's Communication: Research Foundations for Intervention. Baltimore: Paul Brookes Publishing, pp.335-355.
43. Bray, M., and Woolnough, L. (1988). The language skill of children with Down syndrome ages 12-16 years. Child Language Teaching and Therapy, 4(3), 311-324.
44. Meyers, L.F. (1990). Language development and intervention. In D.C. Van Dyke et al., (Eds.), Clinical Perspectives in the Management of Down Syndrome. New York: Springer-Verlag, pp.153-164.
45. Chapman, R.S. and Evans, J.L. (2002). Language development in adolescents with Down syndrome, a research study in progress which is evaluating effective intervention. See http://www.waisman.wisc.edu/adollang/
46. Gray, C. (1994). The new social story book. Arlington, USA: Future Horizons.
47. Passy, J. (1993). Cued articulation and cued vowels. Ponteland, UK: STASS.
48. Nuffield Centre Dyspraxia Programme. London, England: The Nuffield Hearing and Speech Centre.
49. SpeechViewer for Windows [Computer Software]. (1998). Armonk, NY, USA: IBM Corporation.
50. THRASS. Teaching Handwriting, Reading and Spelling Skills. Chester, UK: THRASS. URL: http://www.thrass.co.uk/
51. Kumin, L. (1994). Intelligibility of speech in children with Down syndrome in natural settings: Parents perspectives. Perceptual motor skills, 78, 307-313.
52. Kumin, L. (1994). Communication skills in children with Down syndrome : a guide for parents. Rockville, MD: Woodbine House.
53. Laws, G., Buckley, S. J., Bird, G., MacDonald, J. and Broadley, I. (1995) The influence of reading instruction on language and memory development in children with Down syndrome. Down Syndrome Research and Practice 3(2), 59-64. [Open Access Full Text ]
54. Powell, G., and Clibbens, J. (1994). Actions speak louder than words: Signing and speech intelligibility in adults with Down's syndrome. Down Syndrome Research and Practice, 2(3), 127-129. [Open Access Full Text ]
55. Barker, J. (1999). Singing and music as aids to language development, and its relevance for children with Down syndrome. Down Syndrome News and Update, 1 (3),133-135. [Open Access Full Text ]
56. Horstmeier, D. (1987). Communication intervention. In S.M. Pueschel et al. New Perspectives on Down Syndrome. Baltimore, USA: Paul Brookes Publishing.
57. Grove, N. (1998). Literature for all. London, UK: David Fulton Publishers.

Resources

Some of the books and other resources referenced in this publication are available via Down Syndrome Education International's specialist mail-order service. For further information and a catalogue, please call +44 (0)23 9285 5330, or see http://www.downsed.org/.

Many games and activities to support speech and language work are available. Two companies specialising in these materials are:-

Winslow, Goyt Side Road, Chesterfield, Derbyshire, UK, S40 2PH. Tel: 0845 921 1777 Fax: 01246 551195 Email: sales@winslow-cat.com

STSTASS, 44 North Road, Ponteland, Northumberland NE20 9UR Tel: 01661 822316 Fax: 01661 860440 Email: susan@stass.demon.co.uk

Their catalogues contain useful materials for use by parents, teachers and therapists. The Winslow catalogue also contains a range of computer software designed to aid speech and language development.